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Apr 30, 2016
I posted earlier a link to this article. I didn't realize that registration was needed to view the article. Here is the article.

"Vancouver – “We have less power, pharmacologically, than we thought. The vast majority of people are getting adverse effects in return for nothing,” said Dr. Tom Perry, in a presentation on managing chronic pain in the post-opioid era at last weekend’s BC College of Family Physicians spring family medicine conference.
Dr. Perry is a clinical assistant professor in the departments of anesthesiology, pharmacology and therapeutics at the University of British Columbia. He is also an executive committee member of UBC’s Therapeutics Initiative, which provides independent, evidence-based practical information on prescription drug therapy.
Define your therapeutic goals, he told the audience. Are they relief of suffering, improved function and overall drug safety? Freedom from adverse effects, including sedation and impaired thinking, memory and balance? Or are we simply seeking a better pain score?
The symptomatic effect of drugs is always rapid, usually within the first two days of treatment and seldom beyond a week or two, said Dr. Perry. Therefore, a response to drug therapy should be assessed early and if the dose is increased it should be reassessed within a few days. “One week’s worth of drugs is plenty for pretty much anything. For any pain relief drug, we should be very suspicious of increased doses,” he said.
He reiterated the 2017 Canadian opioid guidelines that recommend optimization of nonopioid pharmacotherapy and nonpharmacologic therapy, rather than a trial of opioids, for patients with chronic noncancer pain.
Dr. Perry pointed out the importance of paying attention to descriptive language in evaluations of drugs. For example, for chronic low back pain, “moderate to high quality evidence” suggests that cyclobenzaprine “may” be more effective than placebo for up to two weeks. But there is no evidence for any benefit from the drug for neck or myofascial pain. For diabetic neuropathy, there is a “suggestion” that gabapentin may help. However, the Therapeutics Initiative found weak evidence for the medication in neuropathic pain in 2000, 2009 and 2010.
Recognize when specialists exaggerate the benefits of drugs, he advised the audience. “They may say that a drug ‘should’ or ‘will’ work. But there is no relation to reality in that opinion,” said Dr. Perry.
Reviewing examples of evidence for the effectiveness of various drugs, Dr. Perry said it is non-existent for multi-modal analgesics. For acute low back pain, a 2017 study found no difference in effectiveness between acetaminophen and placebo. A 2014 Cochrane Review described the drug evidence for diabetic neuropathy and fibromyalgia as “moderate quality” or “low.” The Cochrane Reviews are “equally grim” for tricyclic antidepressants for pain, said Dr. Perry.
“If most drugs don’t help chronic pain but lead to toxicity, you can at least decrease doses or polypharmacy. All I can do is detoxify people,” was Dr. Perry’s frank assessment. Patients should be given discretion in their drug management too, he said.
Dr. Perry suggested that objective, longer-term trials in family practice are needed, as well as mutual support groups for family physicians to help them deal with the complex challenges of pain management."
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