Wednesday, March 7, 2018

pushing non narcotics with fake news

when I was in medical school, we learned that the only pain killer that worked better statistically than various pain killers was morphine. The reason? There is a large placebo effect.

So the placebo effect screws up the data.

I remember an anecdote about a doctor who gave out "green pills": ordinary sugar pills, with a long lecture. Or docs who would give prescriptions of them, to increase the placebo effect. And of course, expensive pills work better than cheap ones.

the whole point is that NSAIDs and tylenol are often cheap and over the counter: make them expensive and they will work better because of the placebo effect.

Similarly, I once heard a lecture by a nephrologist about the problems of NSAIDS in causing kidney disease/failure. But after the lecture, he was asked what he took, and he admitted that he took NSAIDS because the pain relief from Tylenol was lousy.

In my own life, I prefer NSAIDS: even after surgery, I found better pain relief from this than the pecocet that I was prescribed, but you know, in the post op period, the problem was they were giving me two percocet every six hours, meaning I slept for three hours, was good for one, and hurt for two hours. So I took the pills and hid one and gave myself the medicine as needed, not as prescribed.

This is also why long acting medicines (MSContin, Fentanyl patches) work so well: They relieve pain without sedation, without the swing from high to low.

So now the NYTimes is insisting tylenol works as well as narcotics for osteoarthritis pain.

“Should we use opioids if nonopioids don’t work?” asked the lead author, Dr. Erin E. Krebs of the Minneapolis Veterans Affairs Health Care System. She answered her own question: “No. We tried four different nonopioids — don’t give up on them too soon — and we should also be using exercise and rehab for most osteoarthritic pain.”

the study was in the VA system. So not a broad population group.

and remember: Most people just buy over the counter medicine in the first place for this type of pain, so those needing pain pills come for one of three reasons:

one: They hurt despite over the counter medicine. (the reason assumed in the study). Of course, being motivated to be in a study makes the pills magic, and maybe you will take the pills correctly for pain relief, (you have to take pills on schedule so severe pain never develops: Wait until you can't stand the pain and it takes a much higher dose. using over the counter medicine is taken as needed, rarely according to schedule) some will get better pain relief for this reason.

two: They are druggies (how many of the drop outs are these).

Three: The pills are free and they think they are getting magic pills that work because they are in a clinical study. In other words, a better placebo effect.

25 people out of the 240 who finished the study means that ten percent dropped out.

long discussion of the problem of drop outs in clinical studies.

Did they drop out because they hurt?

And how many self medicated with alcohol or borrowing a pain pill.

the P pare not that good either.

In other words, for chronic arthritis, of course you use NSAIDs when possible or tylenol. But how many couldn't sleep at night? (I often gave my patients just a few percocet for night pain).

and how many developed bleeding ulcers or renal problems from the non opioids?


The Power of Nothing: a 2011 article from the New Yorker.

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