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INAPPROPRIATE OPIOID PRESCRIPTIONS RISE AS: PAIN DIAGNOSES DROP; USE OF EVIDENCE-BASED TREATMENT STOPS; LETHAL ODs WITH PRESCRIBED OPIOIDS TREND BACK UP

 

A survey of 21 million patient care records across 50 states shows that the reckless, malfeasant medical treatment of non-medical pain that generated the opioid crisis has not changed

by Clark Miller

Published December 31, 2021

TUESDAY, Dec. 14, 2021 (HealthDay News) — Pandemic lockdowns may have led fewer Americans to seek pain treatment last year, but folks who did seek help had higher-than-usual odds of receiving dangerous opioid painkillers, a new study says.

And that could lead to a worsening of the opioid epidemic, researchers suggest.

“It is likely that more patients may have become addicted to opioids than would have been the case absent the pandemic,” said study lead author Byungkyu Lee, an assistant professor of sociology at Indiana University Bloomington.

Lee and his team tracked treatment patterns for millions of patients struggling with limb, extremity, joint, back and/or neck pain. They found that prescriptions for highly addictive opioid medications like oxycodone (OxyContin) rose 3.5% during the first half-year of the pandemic compared with the prior year — despite a 16% plummet in pain diagnoses.

That’s not all that rose, unfortunately 

As described two weeks ago in this post, In Maryland, Massachusetts, California, Colorado, Virginia, Florida, and Washington, D.C. trends indicate clear increases in 2020 and 2021 in overdose deaths involving doctor-prescribed opioids compared to prior years, consistent with evidence of continued over-prescribing. And consistent with protective shielding of misprescribing by Media-fabricated distracting cover stories empowering and enabling the lethal practices.

The disturbing news from one of multiple states 

is not a surprise, in fact predicted by the failure of all involved trusted American institutions and their watchdog Media to do other than engage in the same collaboration that distorts evidence, protects power, and sacrifices lives and public health to protect established systems. 

As documented here, here, and here, American licensed medical professionals – as evidenced consistently by accumulating, recent reports – continue to over-prescribe and misprescribe the opioids whose reckless, runaway dispensing first generated the crisis. 

opioid pills

The Media/Medical report continues, 

That may be because, in the face of lockdowns, doctors were less likely to turn to nonmedicinal treatments such as massage therapy and other forms of “complementary medicine” like acupuncture and osteopathy. Scripts for such approaches fell by 6% during the same time frame.

“One reason for rising opioid prescriptions during the pandemic is lack of access to non-pharmacologic treatments that require person-to-person contact,” explained Lee.

“Prescribing opioids for pain is a faster and easier ‘no-contact’ solution than physical therapy or complementary medicine,” he noted. “Opioids can be prescribed through telemedicine, for example.”

. . . 

In the new study, the investigators examined data from two time periods: January through September 2019 and January through September 2020 (including the first six months of the pandemic).

About 21 million patients were included in each period. In all, the analysis covered about a fifth of Americans with commercial insurance across all 50 states and roughly a quarter of all Medicare Advantage patients, the authors said.

Investigators compared prescription patterns from April to September of each year.

Not only were there higher opioid prescription rates during the pandemic, but they were at higher doses — roughly equivalent to an additional 1.0 morphine milligrams. Also, prescriptions were written for more than one day longer, on average, than pre-pandemic.

“One reason for rising opioid prescriptions during the pandemic is lack of access to non-pharmacologic treatments that require person-to-person contact,” explained Lee.

“Prescribing opioids for pain is a faster and easier ‘no-contact’ solution than physical therapy or complementary medicine,” he noted. “Opioids can be prescribed through telemedicine, for example.”

As we’ll see below, those are lies – overtly, by deception, and/or by pathological level of diminished capacity for competence and critical thought – that threaten  public health and safety. Lies, that is, constructed for messaging of the same type that generated the opioid crisis by promoting a medical solution for the non-medical issue of common chronic pain. 

Takeaway – Below

As explained and summarized here, below –  despite CDC recommendations from 5 years ago (and despite increasing lethality of American Medicine’s opioid crisis including by prescription opioids), medically trained practitioners have not evidenced clinical nor ethical capacity to change practices to protect public health. 

The medical prescribers, we are asked to believe, felt compelled to turn to increased dispensing of the opioids that generated the opioid crisis because none of the nonpharmacologic treatments could be provided by telehealth, or while avoiding touch or close proximity to patients over pandemic conditions. But that’s a lie, because the one treatment that is supported by research evidence, in contrast to others noted, as being strongly supported for lasting benefit, CBT,  was available through the study period, has always been available, not requiring physical contact or close proximity. It’s the one that wasn’t used by medical providers in the care of their pain patients. 

Cognitive behavioral therapy is the one nonpharmacologic treatment whose use by pain patients cared for by medical professionals was never more than a minute fraction of that of the other “treatments”, the ones not supported by research as effective. 

From the JAMA research article – 

Diagnosis of Pain

For this study, we relied on the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code list that includes a full spectrum of common pain conditions.26 We used a subset of 10 548 ICD-10-CM codes to identify patients with any of these common pain conditions: limb or extremity pain; joint pain and nonsystemic, noninflammatory arthritic disorders; back pain; and neck pain. eTable 1 in the Supplement lists the numbers of patients who received each pain diagnosis cluster in 2019 and 2020.

That is a description of centralized pain . . . as distinct from “peripheral pain”. We need to understand the important difference. 

From a previous post – 

Pain is complex

and in a meaningful way “all pain is in the brain” that is, the experience of the inner state of pain, like all experience, is managed by the brain. For one generalized type of pain – centralized chronic pain – mental and emotional states, not physical or biological, are the basis for its understanding and treatment. Centralized chronic pain, or “brain pain” is understood primarily as distinguished from peripheral pain = pain that is best understood as caused by adaptive (important, useful) signals from non-brain tissues that are inflamed, damaged, or physically impacted (cancer pain) – the experience of pain serves as a useful signal to the organism that an area of the body is injured or impacted, with the potential for responsive behaviors to manage harm and promote healing.

It’s worth thinking about the adaptive (evolutionary), value and function of pain – a signal to the animal to start behaviors likely to increase survival: slow down, stop, get away from potential harm, stop moving, isolate in protective, safe settings, restrict body movement and demands on the body, guard body areas, communicate in ways to get help and protection from others. Perception of pain is complex: modified by mood, stress, beliefs, setting, circumstances, use of substances – tobacco use, for example, heightening perception of chronic pain. Understanding the complexity gives us more angles to use in treatment.

Understanding how we got off track with chronic pain is crucial considering the costs that include: medically mismanaged pain causing the opioid crisis with projected deaths and illness and, for example, an estimated $90 billion annually in wasted healthcare expenditures for inappropriate biomedical treatments just for lower back pain.

Opioid Crisis, ineffective treatments, $billions wasted yearly –

how do we understand chronic pain and treat it more effectively?

Consider the placebo effect – the well-known and common (so common it is supported as possibly accounting for the perceived positive effect of antidepressant medications) experience of a desired change or benefit in wellness, mood, health, often described for depressed mood, caused by getting a fake pill, a sham treatment, often a pill – the physical, chemical, or biomedical nature of that placebo “treatment” without any action or properties to provide such relief or benefit.

There are various explanations for placebo effect. And yet what is common to clinical trials with placebo is the impossibility of achieving an experimental design that truly “controls” (factors out) all relevant factors in the healing process, making it hard to figure out what’s going on, causing the effect.

Or not –

It turns out the factor that can’t be eliminated from placebo trials is the most likely explanation of effect.

In trials with medication placebo it is essentially impossible to factor out (“control”) for the well-established and little known therapeutic factor already established by decades of research to predict the largest share of benefit in all mental health therapy interactions that provide benefit – the common factors approach or Contextual Model of Psychotherapy – describing the large positive therapeutic (healing) effect due to the quality of the therapist-patient (or professional-patient) interaction in sustained individual therapy. Those effective factors, determined by research, are not techniques or therapy procedures, instead intangible factors that “come across” to the patient: like non-judgmental attitude, authenticity (being real), empathic responding, respect for patient integrity and autonomy, collaborative interaction, sense of being heard and understood, sense of safety and trustworthiness of the therapist – factors contributing to patient confidence in and hope for benefit and change, leading to investment in change, working to change.

Those are factors likely to be present to some extent generally in healthcare visits whether the “treatment” is real or sham, an antidepressant or sugar pill, to the extent that the professionals interacted with transmit those intangible supportive factors.

That understanding of placebo effect fits well with and is supported by decades of strong research establishing effectiveness of Cognitive Behavioral Therapy (CBT) which works on the basis of mental or psychological states, specifically held beliefs and belief systems (with or without conscious awareness of them), generating and associated with mood states, inclinations, states of motivation, also physical sensations and experiences, and behaviors including choices.

Doctor with patient discussing medication

Check it out: when I’m frightened by a harmless noise, the physical and emotional sensations I have, generated by my false belief, or interpretation, of the noise are as real as if the noise represented danger, the responses driven by beliefs about the noise, not the noise itself. The extensive, reinforced evidence for effectiveness of CBT and about placebo effect tell us something important: that beliefs are themselves powerful forces driving our experience of inner states including mood, physical sensations, inclinations, behaviors.

woman in chair with back pain

In clinical practice, patients experiencing centralized chronic pain, provided a supportive and inviting setting, reliably express beliefs, clearly distorted yet firmly held, about their pain experiences and associated physical conditions of their bodies, in the context of describing, for example, surgeries and injuries occurring months to years past and in spite of medical imaging and other medical evaluations with no indication of continued pathology or damage.

That is, they mistakenly link their experience of pain – which is real – to tissue damage or lasting  injury, when medical imaging and testing demonstrate no such lasting damage, because physical healing has occurred.

The cognitions (thoughts) are of the type: I’m broken . . . my spine is disintegrating . . . I can’t do anything . . . my foot is destroyed . . . and commonly with themes of acute vulnerability for catastrophic harm: I’ll be in a wheelchair the rest of my life if . . . I move my body the wrong way, or fall, etc. due to distorted beliefs about the fragility of their physical conditions.

The congruent inner states integrated with those distorted beliefs include fear, anxiety, vulnerability, anger, hopelessness, and chronic pain, along with anxious desperation for a medical fix and medical relief from the distressing set of inner experiences.

This is why CBT is the indicated treatment for centralized chronic pain, providing lasting relief, and why the most effective form of CBT for chronic pain is behavioral activation – in this case the paradoxical therapy of encouraging use, more and more use, of the very physical activities, body areas, physical movements that are believed to be broken, fragile, vulnerable, unusable, a threat to the very integrity of the body. CBT works by challenging and changing distorted, self-defeating beliefs, and the most effective way to change beliefs is through experience.

The extensive, reinforced evidence for effectiveness of CBT and about placebo effect tell us something important: that beliefs are themselves powerful forces driving our experience of inner states including mood, physical sensations, inclinations, behaviors.

Once prior, false beliefs that parts of the body are broken, weak, fragile, vulnerable to catastrophic injury are corrected through progressive use – through therapies focused on CBT and behavioral activation – then there is no adaptive value, no “reason” for pain – the functional signal for the organism to behave in ways to protect vulnerable parts of the body – to be generated.

Decades of mutually-reinforcing research and understanding –

of the psychogenic nature of chronic pain; of placebo effect and its meaning; of why CBT works and provides durable relief for chronic pain – establish that centralized chronic pain should never have been treated as a medical condition. Yet current practices for chronic pain (like those for treatment of compulsive substance use) are stuck in doxa: misinformation constructed to serve the interests of industries with the cultural capital to fabricate and establish the misinformation as accepted.

Chronic pain remains treated as if it were a medical, biophysical condition, patients encouraged and trained by what they see on TV and other mass media to access a medical visit, then most often referred to surgeons, or for steroid injections, to medical pain clinics, for massage, chiropractic fixes, other biophysical interventions without support for effectiveness.

Centralized versus peripheral pain

And from a medical journal, the Journal of Dental Research – 

ABSTRACT

Until recently, most clinicians and scientists believed that the experience of pain is perceptually proportional to the amount of incoming peripheral nociceptive drive due to injury or inflammation in the area perceived to be painful. However, many cases of chronic pain have defied this logic, leaving clinicians perplexed as to how patients are experiencing pain with no obvious signs of injury in the periphery. Conversely, there are patients who have a peripheral injury and/or inflammation but little or no pain. What makes some individuals experience intense pain with minimal peripheral nociceptive stimulation and others experience minimal pain with serious injury? It is increasingly well accepted in the scientific community that pain can be generated and maintained or, through other mechanisms, suppressed by changes in the central nervous system, creating a complete mismatch between peripheral nociceptive drive and perceived pain. In fact, there is no known chronic pain condition where the observed extent of peripheral damage reproducibly engenders the same level of pain across individuals. Temporomandibular disorders (TMDs) are no exception. This review focuses on the idea that TMD patients range on a continuum—from those whose pain is generated peripherally to those whose pain is centralized (i.e., generated, exacerbated, and/or maintained by central nervous system mechanisms). This article uses other centralized chronic pain conditions as a guide, and it suggests that the mechanistic variability in TMD pain etiology has prevented us from adequately treating many individuals who are diagnosed with the condition.

Translation: 

“Huh! TMD pain sure seems to be in the brain a lot, not in the jaw, and we don’t know what the heck to make of that.”

We do, though.  Because we just covered the outline to understanding centralized pain, its generation, and implications for treatment. 

From the same article – 

Let’s take a quick look at this table, arguably representing Medicine’s construction of pain. Focus on use of the term “Mechanistic characterization”, the benighted, constructed understanding of pain that gave us American Medicine’s opioid crisis, and this

Translation: peripheral pain is distinctly different from centralized pain. Peripheral pain occurs at a location in the body and is caused by physical effects on nerve endings of: tissue damage (including post-surgery and post-injury), inflammation, and cancer pain. Centralized pain is created in the brain, as we know. It is chronic, tends to be non-localized, and does not respond to medical treatments . . . because it is psychological and psychogenic, not medical. It does not respond to opioids despite, as thoroughly and effectively documented and described by Sam Quinones in Dreamlandthe successful and lethal efforts of a craven, maleficent collusion of American Media, Medicine, public and private healthcare institutions to create a for-profit campaign to dispense addictive opioids to millions of trusting Americans with chronic, centralized pain – now known as the “opioid crisis”. 

That mechanistic, medical construction of the meaning of pain is belied by this reasonable discussion later in the research article –

More generally, levels of depressive/anxious symptoms in TMD appear to be elevated as compared with healthy controls but comparable to other chronic pain conditions (). The same is true of nonspecific somatic complaints (i.e., abdominal pain, unrefreshing sleep; ). There is some evidence that negative affective symptoms are a risk factor for developing TMD. The OPPERA study found a number of psychosocial factors that are associated cross sectionally with chronic TMD, including levels of depression, anxiety, and somatization (). These results were corroborated by prospective analyses (n = 3,263), as levels of global psychological distress and somatic complaints were both robust predictors of incident TMD ().

Of interest to clinicians treating TMD, axis II dimensions (i.e., psychosocial characteristics) have generally been found to be important predictors of treatment outcomes. For instance, levels of depression, catastrophizing, and somatic complaints are strong predictors of a worse response to standard treatment (). Negative affect and psychosocial stress may contribute to the symptoms and incidence of TMD directly, by influencing neural substrates, and/or may indicate common etiologic factors that promote psychological vulnerabilities and chronic pain.

. . . 

The degree of pain centralization for each patient can be taken into account when determining the appropriate pharmacologic therapy. For patients with peripheral/nociceptive noninflammatory pain, acetaminophen and nonsteroidal anti-inflammatory drugs work well. The former is now thought to be safer but less effective than the latter. Although opioids can be effective in certain situations, they are known to be ineffective (and sometimes counterproductive) for chronic pain and are no longer recommended for it. Both inflammatory and noninflammatory peripheral pain syndromes, as well as peripheral neuropathic pain, can be treated with topical agents, anti-inflammatory drugs, or injections, depending on the mechanism.

Patients in whom centralized pain is suspected should generally respond better to drugs with centrally acting mechanisms. Tricyclics have been shown to be effective in some cases (), but they have significant toxicity. Newer drugs that target neurotransmitter systems (e.g., serotonin and norepinephrine) with better selectivity, such as tramadol or duloxetine, are more commonly prescribed. Alpha-2-delta calcium channel ligands, such as gabapentin and pregabalin, have also shown promise in treating centralized pain.

Finally, the potential for nondrug therapies to help individuals with centralized pain should not be overlooked. For example, TMD patients who score high on the biopsychosocial axis of the diagnostic criteria for TMD generally respond less well to peripherally targeted treatments, but for those who score high on this axis (i.e., those with more systemic symptoms and likely some degree of pain centralization), cognitive behavioral therapy has been shown to have some promise in helping them ().

Translation: 

For one very common form of centralized pain, with features similar to fibromyalgia (FM),  it’s like, this isn’t mechanistic, or medical, or what? What do we do? Because there must be, like, some medical fix, something we can prescribe? Like we learned in med school? 

Tricyclics? Toxic. 

Gabapentin? Right on. Gabapentin wouldn’t be one of the most commonly abused prescription drugs would it?

Would it?

There must be some RCTs showing long-term effectiveness of gabapentin for centralized pain with low diversion and abuse, right? Just like there were RCTs showing long-term effectiveness for opioids for chronic pain, right? Right?

Right? 

Please? Anyone? Anyone? 

And, as we note, “Finally”, that is, last mentioned –  there  are psychological treatments for centralized pain that turn out to be effective and long-lasting, something called CBT, for “those with more systemic symptoms and likely some degree of pain centralization”. Wait, so for essentially all TMD patients CBT is the indicated treatment? 

WTF is CBT? “Cognition”, something ? Trying to remember what they said about that in med school. Might have missed it in that one lecture, was working on memorizing the long- versus short-acting benzos. 

Anyway, it “should not be overlooked”, seems a good way to sum it up. Okay, yeah, that’s what the editors wanted,  to approve for publication. 

Well,

it may seem important to actually examine and consider the relative effectiveness of Cognitive Behavioral Therapy versus medical interventions for chronic pain at this point – that is, at a point in time at which a Media/Medical collusion generated an opioid crisis by fabricating a consensus requiring the distortion of evidence to lie about and support the use of the medical intervention of opioid dispensing for all pain including centralized, and now, a point in time at which that manufactured lie has contributed to 100,000 opioid overdose deaths last year.  

So, let’s take a look. From a post published and available three years or so ago – 

 

The best available research on effectiveness of treatments for the most common chronic pain, pain that is “centralized” (not cancer pain or due to acute inflammation or tissue damage) – like lower back pain and fibromyalgia – affirms decades of mutually-confirming lines of research and understanding pointing to basic, widely-available psychotherapies like Cognitive Behavioral Therapy and Behavioral Activation as the effective and durable treatments, yet patient care remains driven by current, ineffective practices with enormous costs in healthcare resources wasted on inappropriate medical/biophysical interventions.

Opioid pill bottles

Chronic pain and its treatment have played central roles in runaway over-prescription of opioid pain medications and the opioid crisis. Understanding how we got off track with chronic pain is crucial considering the costs that include: key role in etiology of the opioid crisis and projected mortality and morbidity and, for example, an estimated $90 billion annually in wasted healthcare expenditures for inappropriate biomedical treatments just for lower back pain.

While inappropriate biophysical interventions continue to suck healthcare funds down that black hole, decades of strong research have established durable effectiveness of Cognitive Behavioral Therapy (CBT) for chronic pain. CBT works with mental or psychological states, specifically held beliefs and belief systems with or without conscious awareness, generating and associated with mood states, inclinations, states of volition, physical sensations and experiences, and behaviors including choices. When I’m frightened by a harmless noise, those sensations generated by my false beliefs about, or interpretation of, the noise are as real as if the noise represented danger, the responses driven by beliefs about something. The extensive, congruent evidence around effectiveness of CBT and other phenomena, like placebo effect, tell us that beliefs are themselves potent forces driving our experience of inner states including mood, physical sensations, inclinations, impetus for behaviors.

In clinical practice, patients experiencing centralized chronic pain, provided a supportive and inviting setting, reliably express beliefs, clearly distorted yet firmly held, about their pain experiences and associated physical conditions of their bodies, in the context of describing, for example, surgeries and injuries occurring months to years past and in spite of medical imaging and other medical evaluations with no indication of continued pathology or damage. The cognitions (thoughts) are of the type: I’m broken . . . my spine is disintegrating . . . I can’t do anything . . . my foot is destroyed . . . and commonly with themes of acute vulnerability for catastrophic harm: I’ll be in a wheelchair the rest of my life if I move my body the wrong way, or fall, etc. due to distorted beliefs about the fragility of their physical conditions. The congruent inner states integrated with those distorted beliefs include fear, anxiety, vulnerability, anger, hopelessness, and chronic pain, along with anxious desperation for a medical fix and medical relief from the distressing set of inner experiences.

Enter Cognitive Behavioral Therapy – CBT :

The Paradoxical, Indicated, Effective and Lasting Treatment for Chronic Pain

That is why CBT is the indicated treatment for centralized chronic pain, providing durable relief, and why the most effective form of CBT for chronic pain is Behavioral Activation integrated with other CBT approaches – in this case the paradoxical therapy of encouraging use, more and more use, of the very physical activities/body areas/physical movements that are believed to be broken, fragile, vulnerable, unusable. CBT works by challenging and changing distorted, self-defeating beliefs, and the most effective way to change beliefs is through experience.

What does the most current research say about the nature of chronic pain and its effective treatment?

See this companion post for a more thorough discussion of psychotherapies for centralized chronic pain (CCP).

Discrepant results –

Interventions provided to produce benefit through biophysical changes/manipulation (“Biophysical therapies” targeting, for example, relaxed musculature, reduced inflammation) lack strong evidence and long-term benefit with one exception: keeping active, regular physical exercise, return to physical functioning. That result generates useful hypotheses allowing additional evaluation.

1) Prediction under hypothesis of biophysical nature and effective medical therapies for CCP:

Interventions that target and predict biophysical changes (Type 1) will, as a group, be effective.

2) Prediction under hypothesis of psychogenic/psychosocial/behavioral nature and effective therapies for CCP:

Interventions that target and predict change in pain-related, self-defeating cognitions (e.g. “I’m broken”, “I can’t”, “I’m fragile, injured”) and associated mood states (fearfulness, anxiety, helplessness, etc.) will, as a group, be effective (Type 2).

Status of  The Evidence:

Look at the table. Interventions that predict Type 2 factors (CBT mediated by talk therapy and structured experience through behavioral activation) are supported strongly by evidence for significant long-term effects.

Interventions that predict Type 1 factors are not supported as effective and durable.

Evidence-based indicated treatments:

Based on longstanding evidence and understanding, affirmed by the most current research, chronic centralized pain is psychogenic and psychosocial in nature and etiology. Congruently, the indicated evidence-based, effective, durable treatment is CBT with cognitive restructuring including experiential disputation through behavioral activation (by paradoxical and successful return to use of the protected body parts believed to be fragile, unusable) – of maladaptive, self-defeating cognitions e.g. “I’m broken”, “I’m fragile, injured, “I can’t”.

Congruently, biophysical interventions that are passive and do not predict experientially-mediated cognitive restructuring (e.g. massage, acupuncture), do not predict durable gains in pain moderation measures.

surgeons performing surgery

Chronic pain remains treated as if it were a medical, biophysical condition, patients referred by medical providers and trained by what they see on TV and other mass media to access a medical visit.

Then they are most often referred to surgeons, or for steroid injections, to medical pain clinics, for massage, chiropractic fixes, other ineffective and invalidated biophysical interventions.

 

Continuation of scheduling of patients with chronic pain complaints with their PCP or a medical provider makes as much sense as prescribing opioid medications for chronic pain, both predicting waste and harm.

Standing against efforts for change and reduced harm, the burden of decades of a nation of patients trained to access medical care for non-medical problems, with the expectation of a pill or other physical intervention as a fix, has created a formidable barrier to change that threatens multibillion dollar industries. That domestication, training, for quick medical fixes – for everything from addiction, smoking, to chronic pain, to depressed mood – is woven solidly into our Matrix, is Bourdieu’s Doxa, forms of social pathology.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.”

– Pierre Bourdieu  Outline of a Theory of Practice (1972)

In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.

References, links

  1. Cherkin DC, Anderson ML, Sherman KJ, Balderson BH, Cook AJ, Hansen KE, Turner JA. Two-Year Follow-up of a Randomized Clinical Trial of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care for Chronic Low Back Pain. JAMA. 2017;317(6):642–644. doi:10.1001/jama.2016.17814
  2. Richmond H, Hall AM, Copsey B, et al. The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis. Bencharit S, ed. PLoS ONE. 2015;10(8): e0134192. doi:10.1371/journal.pone.0134192.
  3. Hofmann SG, Asnaani A, Vonk IJJ, Sawyer AT, Fang A. The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive therapy and research. 2012;36(5):427-440.

References, links

2017 review by American College of Physicians:

  1. Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017; 166:493–505. doi: 10.7326/M16-2459
  2. van Middelkoop, M., Rubinstein, S.M., Kuijpers, T. et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J (2011) 20: 19. https://doi.org/10.1007/s00586-010-1518-3

Current compilation of Cochrane, other reviews of primary research:

  1. https://www.vox.com/science-and-health/2017/8/4/15929484/chronic-back-pain-treatment-mainstream-vs-alternative

Where were we? 

Right. 

The question of whether Cognitive Behavioral Therapy – the one treatment for most pain suffered by Americans (common chronic, or “centralized” pain) that is supported by evidence as effective and long-lasting – as the medical researchers recommended, “should not be overlooked”. 

As opposed to, say, opioid pills listed as Schedule II controlled substances due to addictive potential and never evidenced as effective for chronic pain – a medical treatment that certainly was not overlooked as a “treatment” in the history of American Science and  Medicine. 

headline on 2020 opioid overdose deaths

Back to the JAMA article – 

to gain an understanding of how American Medicine, in the wake of its increasingly lethal opioid crisis, generated by provision of evidence-free medical fixes for the non-medical condition of  common chronic pain, has responded and adjusted with care for pain patients. 

Here’s how: 

Wow. That’s interesting. Let’s compare eTAble 4 to the table of research results explained above in this post outlining what current research says about the medical/biophysical interventions versus psychological/psychosocial = CBT, Cognitive behavioral therapy. The numbers link to the peer-reviewed research/review articles cited above in this post. 

For massage, acupuncture, physical therapy – “Weak evidence” with benefit, if any “short-term”. 

Now look back at eTable 4: those interventions favored, in apparent referrals, by orders of magnitude, that is, more frequently by factors of 100 times to more than 1,000 times greater, over use of CBT by their patients with chronic pain. But that doesn’t quite capture it, does it? Use of the one therapy evidenced as providing real, lasting relief from common chronic pain – Cognitive Behavioral Therapy – was never used more than a tiny faction of the time, and was extinguished to no use. 

But what about the popular TENS,

“Transcutaneous electrical nerve stimulation”? That’s not included in the lower table pointing to research on effectiveness, and, by just the sound of it, it seems quite important, like it’s something bioengineered or something? We can imagine a licensed medical professional learning about that in med school, and that same medical professional imagining herself uttering that, pronounced accurately and casually, “Transcutaneous electrical nerve stimulation” to patients in pain, perhaps to colleagues as well, “Transcutaneous electrical nerve stimulation”. Cool. 

TENS was used more than CBT by factors of 100 to 10,000 times more frequently by pain patients cared for by medical professionals who were also turning to increased use of opioid medications. So it must be quite effective. 

Let’s just check to see what the research says about TENS.  

Does it work?

Due to a lack of high-quality research and clinical trials, researchers have not yet determined whether TENS is a reliable treatment for pain relief.

One study (Trusted Source) found that TENS treatment provided temporary pain relief for people with fibromyalgia while the machine was in use.

While there is a lack of strong clinical evidence for its effectiveness, TENS is a low-risk pain relief option for many people.

. . .

Tolerance

Research shows (Trusted Source) that people who use a TENS unit on a daily basis at the same frequency and intensity can develop a tolerance to the treatment.

A person who develops tolerance will no longer feel the same level of pain relief that they did when they first used the unit.

. . .

How long does pain relief last?

The duration of pain relief after using a TENS unit can vary. Some people report that their pain returns as soon as they switch off the device. Others continue to experience an adequate level of pain relief for up to 24 hours.

. . .

Takeaway

The research on using a TENS unit for pain relief has so far yielded inconsistent results due to a lack of high-quality scientific studies and clinical trials.

Huh! 

“while the machine was in use”

“pain relief for up to 24 hours”

“lack of strong clinical evidence for its effectiveness”

Surprised? 

Let’s return to the article in JAMA, American Medicine’s top, authoritative medical research journal. 

In 2016, the Centers for Disease Control and Prevention recommended use of nonpharmacologic therapy and nonopioid pharmacologic therapy instead of or in combination with opioid therapy because those options effectively reduce pain and improve physical function without the risk of addiction.12,13 Because these recommendations alone have not had significant effects on the opioid epidemic, policies that target the opioid epidemic have continued to focus on managing and controlling the supply of prescription opioids.33 Recent studies24,34,35 have found that the success of these policies—shorter duration and lower volume of opioid prescriptions—is not sufficient to reverse the increasing trends in opioid overdose mortality. Against this background, our findings regarding the substitution of nonpharmacologic therapy with opioid therapy during the COVID-19 pandemic suggest that policies that markedly expand the use of nonaddictive treatments, such as physical therapy for chronic pain management, are urgently needed.

Although the proliferation of telemedicine during the COVID-19 pandemic36 may have contributed to the substitution of nonpharmacologic therapy with opioid prescriptions, virtual nonpharmacologic therapy holds potential to help reduce disparities caused by unequal access to in-person nonpharmacologic therapy. Although certain procedures require direct in-person contact (eg, deep tissue massage), other forms of therapy can be effectively provided remotely through telemedicine (eg, certain physical therapies).37 Although the digital divide remains a problem, especially in rural areas and among patients with low socioeconomic status,38,39 telemedicine could be a viable strategy to provide nonpharmacologic therapy to patients with pain under social distancing or to those in areas with a shortage of health care professionals.

These findings on pain management should be considered in the context of pandemic-associated changes in the opioid epidemic. Recent estimates from the Centers for Disease Control and Prevention suggest that more than 81 000 drug overdose deaths occurred in the US in the 12 months ending in May 2020.2 This estimate is the highest number of overdose deaths ever recorded in a 12-month period. This recent increase in overdose mortality is a sharp deviation from trends before the pandemic. Specifically, during 2017 to 2018, opioid-involved overdose deaths had decreased for the first time since 1999. Although synthetic opioids appear to be driving the increase in overdose deaths, increasing 38.4% from the prior year, our findings on excessive exposure to prescription opioids during the pandemic may portend future problems, potentially disrupting large-scale public health efforts to reduce inappropriate prescribing and encourage nonpharmacologic therapies for pain.

. . . 

Conclusions

Projecting beyond the pandemic, our findings on substitution of nonpharmacologic therapy with opioids may have broader implications for health disparities.40 We found that under conditions of reduced access to diverse treatment options, practitioners and patients resorted to riskier alternatives to manage acute and chronic pain. After the pandemic, nonpharmacologic therapy will likely continue to be inaccessible for many patients because of factors such as cost, underinsurance, lack of transportation, lack of childcare, or inability to take time off work. These barriers disproportionately affect people in rural areas, Black and Latinx patients, gender and sex minorities, and those in disadvantaged socioeconomic groups41-43 and thus may contribute to broader disparities in opioid use disorders and overdose. It is critical to increase universal access to nonpharmacologic treatments for pain management by reducing these barriers.

What’s being said here? 

First, that despite CDC recommendations from 5 years ago (and despite increasing lethality of American Medicine’s opioid crisis including by prescription opioids), medically trained practitioners have not evidenced clinical nor ethical capacity to change practices to protect public health. 

Followed by the weak deceptions and rationalizations: that the medical prescribers, we are asked to believe, felt compelled to turn to increased dispensing of the opioids that generated the opioid crisis because none of the nonpharmacologic treatments could be provided by telehealth, or while avoiding touch or close proximity to patients over pandemic conditions . . . except, we must note, the one treatment that is supported by research evidence, in contrast to others noted, as being strongly supported for lasting benefit. The one whose use by pain patients cared for by medical professionals was never more than a minute fraction of that of the ineffective “treatments”, the one whose use over the study period stopped, ended. 

Weak deceptions and rationalizations because, as established by the evidence, by longstanding research, the one “nonpharmacologic” treatment for common chronic pain providing effective and lasting relief, CBT,  was available through the study period, has always been available, not requiring physical contact or close proximity. Therapy occurs most effectively in an office setting, at social distances of 6 feet, or 10 feet, or 12 feet if indicated. It can be provided readily – is being provided routinely – by telehealth, albeit less effectively than in-person. 

There is no excuse, no rationalization. And no accountability. 

Just the predictable lies, the  pathological levels of incompetence and diminished capacity, the reckless, malfeasant, criminal assault on public health. 

Just the inability of sick, harm-predicting systems to change.

The need to take the power back. 

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

Pierre Bourdieu - Outline of a Theory of Practice 1972

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