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“I was a little surprised”: Qualitative Insights from Patients Enrolled in a 12-Month Trial Comparing Opioids to Non-Opioid Medications for Chronic Musculoskeletal Pain

Chronic musculoskeletal pain is a major public health problem, associated with disabling physical and emotional consequences for patients and with significant costs related to medical treatment and lost worker productivity.16 Use of opioid analgesics to treat chronic pain has increased dramatically in recent years,7,25 paralleled by increases in opioid-related harms, including addiction and death.1,23,34 While harms of opioids have become apparent, evidence for long-term effectiveness of opioids for chronic pain is lacking; a recent systematic review found no randomized trials that examined effects of opioids on pain, function, or quality of life at one year or longer.

“I was a little surprised”: Qualitative Insights from Patients Enrolled in a 12-Month Trial Comparing Opioids to Non-Opioid Medications for Chronic Musculoskeletal Pain

Orginally Published At: Pain Journal

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Prevalence and Correlates of Low Pain Interference among Patients with High Pain Intensity who are Prescribed Long-Term Opioid Therapy

Chronic pain is a multifaceted experience that involves physiological, psychological, and situational components.17 The experience of pain may vary widely among individuals; differences have been observed by gender,51 ethnicity,32,42 and even certain personality characteristics.41 The pain experience may also vary greatly among individuals reporting equally high levels of pain; while one may function poorly in several areas, another may experience minimal pain-related interference. Although sophisticated diagnostic tools (e.g., imaging studies) can assess anatomic contributions to pain, these are not reliable predictors of the extent to which pain affects functioning, disability, or quality of life.

Prevalence and Correlates of Low Pain Interference among Patients with High Pain Intensity who are Prescribed Long-Term Opioid Therapy

Orginally Published At: Pain Journal

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Why so many things help chronic pain a little bit

An excerpt from my transcutaneous electrical stimulation (TENS) article, describing an important basic principle that explains why so many people “swear by” so many different kinds of treatment methods:

Pain is completely controlled by an overprotective brain that likes to sound the alarm too loudly, too often, regardless of what’s actually going on in tissues. This means that most kinds of chronic pain are partially and briefly treatable with tricks and hacks. Almost any reassuring and/or distracting input has some potential to persuade the brain to dial pain down a bit, by fooling a brain into thinking there’s no cause for alarm, at least for a little while. Brief, modest treatment results for chronic pain are mostly about how pain works… not how the treatment works.

Unfortunately, your brain is stubborn and it’s hard to convince it to shut up about pain completely, short of knocking it out, which is why anaesthesia is the only truly effective analgesia.

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Why so many things help chronic pain a little bit


Orginally Published At: Pain Science

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“Adrenal fatigue” is not a thing

Adrenal fatigue was invented by a chiro so he could sell a cure. It is supposedly caused by chronic stress and “burnout” of the adrenal glands, and it’s a common bogus explanation (see Cadegiani et al) for fibromyalgia and chronic widespread pain. At best, that’s a simplistic guess; at worst, it’s a great way to peddle false hope to fibromyalgia patients.

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“Adrenal fatigue” is not a thing


Orginally Published At: Pain Science

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Dr. Travell “dry needled” with a harpoon

I’ve been working on series of updates to the dry needling chapter in my trigger points book, gradually building it up to the point where it would make a good, substantive article on this topic in its own right. It must stay in the book, but here’s an interesting excerpt that I just have to share with everyone today.

A little context first, though: modern dry needling involves stabbing “trigger points” (sore spots in soft tissue of unknown origin) with acupuncture needles. Overlap between acupuncture and dry needling is partial/confusing, but the use of acupuncture needles for this purpose today is almost universal. No one’s using anything else. Which makes this rather interesting…

The term “dry needling” came from Dr. Janet Travell herself, many moons ago. In the original big red books, she used the term to describe lancing a trigger point with a hypodermic needle, but not injecting anything. (Ouch!) She did not go into any detail, but her method is definitely distinct from modern dry needling, which is much more directly “inspired” by acupuncture. Although Travell didn’t explain her rationale for dry needling, she did explain why she never used an acupuncture needle: she thought they were too fine!

There has never been a shred of empirical evidence that suggests that any rationale for dry needling is superior to any other. Like mutually exclusive religious beliefs, they clearly can’t all be right. The fact that Dr. Travell disapproved of acupuncture needles is fascinating and irksome — she is virtually worshipped, her book is still the bible of trigger point therapy… and yet no one using acupuncture needles today has offered an explanation of why they are ignoring her opinion on this. If she was wrong, then it casts doubt on the Mother of Trigger Point Therapy (doubt that is absent from nearly all references to her work). If she was right, then dry needlers have been barking up the wrong tree for a long time.

Or perhaps they are all wrong. Because how dry needling might work is a moot point if it doesn’t work. So…

And then the book continues with an evidence review that does not have a happy ending.


[Image caption] One hypothesis is that stabbing “inactivates” trigger points by wrecking the neuromuscular junction (motor endplate). Here’s four of those, at the ends of branching motor neurons, attaching to muscle fibres. Each one is about 3µm (.03mm) wide, roughly a tenth the diameter of an acupuncture needle. Trying to hit one of these like trying to use a spear to stab a raisin under a metre of Jello. Or a harpoon, if you’re using a hypodermic needle.

The “negative” trigger point book

My trigger point book is a 130,000-word beast, much longer than the average novel, and there are chapters in there I haven’t touched in a decade, like boxes in your attic that contain God-knows-what. Sometimes I open it to a random location, read three paragraphs that make my head explode, and I have to spend the morning bringing it up-to-date (instead of whatever 62 things were on my to-do list).

I never stop modernizing my books, and in the case of the trigger points book, “modernizing” mostly means making it more of a bummer for people who want to believe that trigger points are the key to all pain. It’s the only book about trigger points that discourages people from getting too overheated about trigger points. It’s all about managing expectations now, and the chapter on needling is an excellent example of this trend.

(If you think trigger points “don’t exist” and/or you’re still unclear on why I am not much more dismissive of the idea of trigger points than I am — I do still sell a book about them, after all, even if it is relatively “negative” — my position on this controversial topic is exhaustively spelled out here: Trigger Point Doubts. The highlights are covered by about dozen bullet points early in the article.)

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Dr. Travell “dry needled” with a harpoon


Orginally Published At: Pain Science

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Prescription Medication Use among Community-Based US Adults with Chronic Low Back Pain: a Cross-Sectional Population Based Study.

• Opioids were the most common prescription pain medications among US adults with cLBP.• Opioids were typically used long-term, and combined with other CNS-active agents.• Low level of education was strongly associated with opioid use in cLBP population.

Prescription Medication Use among Community-Based US Adults with Chronic Low Back Pain: a Cross-Sectional Population Based Study.

Orginally Published At: Pain Journal

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Randomized Controlled Trial of Nurse-Delivered Cognitive Behavioral Therapy Versus Supportive Psychotherapy Telehealth Interventions for Chronic Back Pain

• Two telephone-adapted behavioral therapies improved chronic low back pain• A nurse-delivered cognitive behavior therapy reduced pain and improved function• A nurse-delivered supportive care improved pain outcomes equivalent to CBT• Effect sizes were moderate, ranging from .33-.60 for pain severity and function.• 27-39% of the participants reported “much improved” or “very much improved”

Randomized Controlled Trial of Nurse-Delivered Cognitive Behavioral Therapy Versus Supportive Psychotherapy Telehealth Interventions for Chronic Back Pain

Orginally Published At: Pain Journal

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Swapping back pain scapegoats

This little article about back pain wisely challenges the fearful assumption that spines are fragile, and that’s great… but unfortunately it just shifts the blame to “weakness” instead. Sure, exercise is pretty good for back pain — that is well established — but probably not because backs are weak.

How about we stop blaming back pain on any tangible property of the spine? Fragility, weakness, posture, degeneration, etc…they all miss the point. Pain (especially chronic pain) is multifactorial and neurological by nature and rarely has a tidy physical explanation or solution. We need to be okay with that.

Personally, I would prefer to have a strong back, because reasons… but “back pain insurance” is far down the list. We can sing the praises of a strong back all we like: the people who have both strong backs and pain are not going to go away, and there’s plenty of them. There is no compelling evidence that weakness is a risk factor for back pain.

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Swapping back pain scapegoats


Orginally Published At: Pain Science

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Hypnosis Enhances the Effects of Pain Education in Patients with Chronic Non-Specific Low Back Pain: a Randomized Controlled Trial

• Hypnosis can be combined with education in patients with chronic low back pain.• The addition of hypnosis improves pain intensity, disability, and catastrophizing.• The beneficial effects are enhanced, at least in the short and medium-term.• The intervention can be offered in group settings.

Hypnosis Enhances the Effects of Pain Education in Patients with Chronic Non-Specific Low Back Pain: a Randomized Controlled Trial

Orginally Published At: Pain Journal

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Ethical considerations in the design, execution, and analysis of clinical trials of chronic pain treatments

Introduction:
In the field of
pain research, clinical trials may randomize over 500 subjects and include more than 150 sites spanning over a dozen countries.
Methods:
This review examines the ethical considerations affecting clinical trial design, execution, and analysis of trials for chronic pain. The Belmont Report has been the touchstone for human studies protection efforts since 1979. Commissioned by the U.S. government in response to ethical failures in medical research, such as the Tuskegee Syphilis Study, the report emphasizes 3 basic principles: respect for persons, beneficence, and justice. Trial design and sample size have important ethical implications.
Conclusions:
Measures to enhance trial transparency and combat publication and many other types of bias should be implemented.
This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author. Address: California Pacific Medical Center Research Institute, 475 Brannan St, Suite 130 San Francisco, CA 94107. Tel.: 415-600-1750; fax: 415-600-1725. E-mail address: mcrowbotham@gmail.com (M.C. Rowbotham).
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Received August 10, 2017
Received in revised form February 18, 2018
Accepted February 24, 2018
© 2018 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The International Association for the Study of Pain.

Ethical considerations in the design, execution, and analysis of clinical trials of chronic pain treatments


Orginally Published At: PAIN Reports