# Neuropathy: is opioid crisis diminishing access to pain management? **URL:** \ **Category:** Nerves\ **Tags:** pain\ **Created:** [June 2, 2017, 7:18pm UTC](https://forum.fudiabetes.org/t/neuropathy-is-opioid-crisis-diminishing-access-to-pain-management/1128 "2017-06-02T19:18:52Z")\ **Posts on this page:** 10\ **Page:** 1

**Author:** ![Michel](https://yyz2.discourse-cdn.com/flex030/user_avatar/forum.fudiabetes.org/michel/32/387_2.png) [@Michel](https://forum.fudiabetes.org/u/Michel)\ **Post date:** [June 2, 2017, 7:18pm UTC](https://forum.fudiabetes.org/t/neuropathy-is-opioid-crisis-diminishing-access-to-pain-management/1128/1 "2017-06-02T19:18:52Z")

This physician, Dr. Thomas F. Kline, who used to be head of the Hospital in Home service at Harvard Medical School, thinks that it does so unnecessarily: [http://www.newsobserver.com/opinion/op-ed/article145348794.html](http://www.newsobserver.com/opinion/op-ed/article145348794.html) It appears that the new limits on opioid use will significantly impact people with chronic pain:( ---

**Author:** ![TiaG](https://yyz2.discourse-cdn.com/flex030/user_avatar/forum.fudiabetes.org/tiag/32/594_2.png) [@TiaG](https://forum.fudiabetes.org/u/TiaG)\ **Post date:** [June 2, 2017, 7:25pm UTC](https://forum.fudiabetes.org/t/neuropathy-is-opioid-crisis-diminishing-access-to-pain-management/1128/2 "2017-06-02T19:25:51Z")

So this is one of those huge debates – some will argue that opioids are not the best option for neuropathic pain anyway and that relying on them may actually prevent people from focusing on more effective long-term treatments for neuropathic pain. Personally, I’d go with a cannabinoid-receptor drug any day over an opioid for that. Here’s a meta-analysis to that effect: > > > This is an updated version of the original Cochrane review published in Issue 3, 2006, which included 23 trials. The use of opioids for neuropathic pain remains controversial. Studies have been small, have yielded equivocal results, and have not established the long-term profile of benefits and risks for people with neuropathic pain.To reassess the efficacy and safety of opioid agonists for the treatment of neuropathic pain.We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (to 24th October 2012), MEDLINE (1966 to 24th October 2012 ), and EMBASE (1980 to 24th October 2012) for articles in any language, and reference lists of reviews and retrieved articles.We included randomized controlled trials (RCTs) in which opioid agonists were given to treat central or peripheral neuropathic pain of any etiology. Pain was assessed using validated instruments, and adverse events were reported. We excluded studies in which drugs other than opioid agonists were combined with opioids or opioids were administered epidurally or intrathecally.Two review authors independently extracted data and included demographic variables, diagnoses, interventions, efficacy, and adverse effects.Thirty-one trials met our inclusion criteria, studying 10 different opioids: 23 studies from the original 2006 review and eight additional studies from this updated review.Seventeen studies (392 participants with neuropathic pain, average 22 participants per study) provided efficacy data for acute exposure to opioids over less than 24 hours. Sixteen reported pain outcomes, with contradictory results; 8/16 reported less pain with opioids than placebo, 2/16 reported that some but not all participants benefited, 5/16 reported no difference, and 1/16 reported equivocal results. Six studies with about 170 participants indicated that mean pain scores with opioid were about 15/100 points less than placebo.Fourteen studies (845 participants, average 60 participants per study) were of intermediate duration lasting 12 weeks or less; most studies lasted less than six weeks. Most studies used imputation methods for participant withdrawal known to be associated with considerable bias; none used a method known not to be associated with bias. The evidence, therefore, derives from studies predominantly with features likely to overestimate treatment effects, i.e. small size, short duration, and potentially inadequate handling of dropouts. All demonstrated opioid efficacy for spontaneous neuropathic pain. Meta-analysis demonstrated at least 33% pain relief in 57% of participants receiving an opioid versus 34% of those receiving placebo. The overall point estimate of risk difference was 0.25 (95% confidence interval (CI) 0.13 to 0.37, P \< 0.0001), translating to a number needed to treat for an additional beneficial outcome (NNTB) of 4.0 (95% CI 2.7 to 7.7). When the number of participants achieving at least 50% pain relief was analyzed, the overall point estimate of risk difference between opioids (47%) and placebo (30%) was 0.17 (95% CI 0.02 to 0.33, P = 0.03), translating to an NNTB of 5.9 (3.0 to 50.0). In the updated review, opioids did not demonstrate improvement in many aspects of emotional or physical functioning, as measured by various validated questionnaires. Constipation was the most common adverse event (34% opioid versus 9% placebo: number needed to treat for an additional harmful outcome (NNTH) 4.0; 95% CI 3.0 to 5.6), followed by drowsiness (29% opioid versus 14% placebo: NNTH 7.1; 95% CI 4.0 to 33.3), nausea (27% opioid versus 9% placebo: NNTH 6.3; 95% CI 4.0 to 12.5), dizziness (22% opioid versus 8% placebo: NNTH 7.1; 95% CI 5.6 to 10.0), and vomiting (12% opioid versus 4% placebo: NNTH 12.5; 95% CI 6.7 to 100.0). More participants withdrew from opioid treatment due to adverse events (13%) than from placebo (4%) (NNTH 12.5; 95% CI 8.3 to 25.0). Conversely, more participants receiving placebo withdrew due to lack of efficacy (12%) versus (2%) receiving opioids (NNTH -11.1; 95% CI -20.0 to -8.3).Since the last version of this review, new studies were found providing additional information. Data were reanalyzed but the results did not alter any of our previously published conclusions. Short-term studies provide only equivocal evidence regarding the efficacy of opioids in reducing the intensity of neuropathic pain. Intermediate-term studies demonstrated significant efficacy of opioids over placebo, but these results are likely to be subject to significant bias because of small size, short duration, and potentially inadequate handling of dropouts. Analgesic efficacy of opioids in chronic neuropathic pain is subject to considerable uncertainty. Reported adverse events of opioids were common but not life-threatening. Further randomized controlled trials are needed to establish unbiased estimates of long-term efficacy, safety (including addiction potential), and effects on quality of life. And a cannabinoid one: > **[Cannabinoids as pharmacotherapies for neuropathic pain: From the bench to the...](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2755639/)** > > Neuropathic pain is a debilitating form of chronic pain resulting from nerve injury, disease states, or toxic insults. Neuropathic pain is often refractory to conventional pharmacotherapies, necessitating validation of novel analgesics. Cannabinoids,... Also, when it comes to chronic pain, most newer science suggests that using opioids isn’t a great option because it ultimately heightens pain sensitivity and lowers pain threshold. [https://novusdetox.com/opioid-pain-effects.php](https://novusdetox.com/opioid-pain-effects.php) ---

**Author:** ![docslotnick](https://yyz2.discourse-cdn.com/flex030/user_avatar/forum.fudiabetes.org/docslotnick/32/75_2.png) [@docslotnick](https://forum.fudiabetes.org/u/docslotnick)\ **Post date:** [June 2, 2017, 7:42pm UTC](https://forum.fudiabetes.org/t/neuropathy-is-opioid-crisis-diminishing-access-to-pain-management/1128/3 "2017-06-02T19:42:28Z")

It’s not only a bane for neuropathy, it’s also one for short term pain. As a prescriber I am almost made to feel like a criminal for prescribing hydrocodone for my patients. Not to mention the hoops I need to jump through to do so. Our government is trying to cover up their own complicity in the illicit use of opioids and shifting the blame to prescribers. Again, a case of our government instead of doctors making treatment decisions for patients. ---

**Author:** ![TiaG](https://yyz2.discourse-cdn.com/flex030/user_avatar/forum.fudiabetes.org/tiag/32/594_2.png) [@TiaG](https://forum.fudiabetes.org/u/TiaG)\ **Post date:** [June 2, 2017, 8:10pm UTC](https://forum.fudiabetes.org/t/neuropathy-is-opioid-crisis-diminishing-access-to-pain-management/1128/4 "2017-06-02T20:10:01Z")

I think the case for using it for surgical pain, though, is stronger than it is for neuropathic pain. I don’t think doctors should have someone from DEA breathing over their shoulders preventing them from prescribing opioids. But\*, I do think there should be a huge voluntary push from within each medical specialty to reduce the default use of them, and to change best practices on how they’re prescribed. For instance, after my C-section, I think they gave me a huge number of Vicodin pills that lasted a month. I think it makes more sense for the standard to be for fewer pills at discharge, since only a small fraction of patients need that many. And I also think guidelines for non-pain specialties need to take a look at the newest evidence and not just default to opioids when in fact an NSAID or other medication might even be better. ---

**Author:** ![TiaG](https://yyz2.discourse-cdn.com/flex030/user_avatar/forum.fudiabetes.org/tiag/32/594_2.png) [@TiaG](https://forum.fudiabetes.org/u/TiaG)\ **Post date:** [June 2, 2017, 8:10pm UTC](https://forum.fudiabetes.org/t/neuropathy-is-opioid-crisis-diminishing-access-to-pain-management/1128/5 "2017-06-02T20:10:32Z")

what do you mean the government’s complicity in the illicit use of opioids? Can you elaborate on that? ---

**Author:** ![cardamom](https://yyz2.discourse-cdn.com/flex030/user_avatar/forum.fudiabetes.org/cardamom/32/2622_2.png) [@cardamom](https://forum.fudiabetes.org/u/cardamom)\ **Post date:** [June 2, 2017, 8:59pm UTC](https://forum.fudiabetes.org/t/neuropathy-is-opioid-crisis-diminishing-access-to-pain-management/1128/6 "2017-06-02T20:59:04Z")

Yeah, as @TiaG notes, I’d lean away from opiate treatment for neuropathy for other reasons anyway—not generally that effective, lots of side effects, as well as habit forming. Gabapentin, SNRIs, TCAs etc, are better first-line treatments, and if it were me and those didn’t work, I’d probably then try a cannabinoid over an opiate. The issue is an important one for pain treatment more broadly though. ---

**Author:** ![Michel](https://yyz2.discourse-cdn.com/flex030/user_avatar/forum.fudiabetes.org/michel/32/387_2.png) [@Michel](https://forum.fudiabetes.org/u/Michel)\ **Post date:** [June 2, 2017, 10:21pm UTC](https://forum.fudiabetes.org/t/neuropathy-is-opioid-crisis-diminishing-access-to-pain-management/1128/7 "2017-06-02T22:21:10Z")

Here is a twitter comment from Dr. Kline, upon reading our post: “Neuropathy is awful. I found opiates worked best – far less side effects than overly expensive lyrica working no better than generic dilantin.” ---

**Author:** ![docslotnick](https://yyz2.discourse-cdn.com/flex030/user_avatar/forum.fudiabetes.org/docslotnick/32/75_2.png) [@docslotnick](https://forum.fudiabetes.org/u/docslotnick)\ **Post date:** [June 2, 2017, 10:48pm UTC](https://forum.fudiabetes.org/t/neuropathy-is-opioid-crisis-diminishing-access-to-pain-management/1128/8 "2017-06-02T22:48:08Z")

> [@TiaG](#): > > what do you mean the government’s complicity in the illicit use of opioids? Can you elaborate on that? I think stated my position ineloquently. What I was alluding to is the way that government has a knee jerk response to drugs, making them less available to doctors and their patients. As Dr. Kline stated, very few people who are prescribed opiates become addicted, yet many of these chronic pain patients still have pain. They are more likely in the absence of a medical prescription to attempt the procurement of drugs illegally to relieve their pain. I’m sure that in many cases they don’t go out and buy hydrocodone, but they buy something stronger with higher addiction potential. The bottom line is that I trust my doctors to do the right thing more than I trust my government to do the right thing. ---

**Author:** ![TiaG](https://yyz2.discourse-cdn.com/flex030/user_avatar/forum.fudiabetes.org/tiag/32/594_2.png) [@TiaG](https://forum.fudiabetes.org/u/TiaG)\ **Post date:** [June 2, 2017, 11:52pm UTC](https://forum.fudiabetes.org/t/neuropathy-is-opioid-crisis-diminishing-access-to-pain-management/1128/9 "2017-06-02T23:52:02Z")

ah, ok. Somehow I thought you meant the government was selling heroin on the streets or part of some deliberate conspiracy to increase drug use. I actually broadly agree with you because I generally think the War on Drugs and our entire approach to scheduled drugs has failed. But I probably disagree on the extent to which overprescribing is a contributing factor to the opioid epidemic. While it’s likely true that “very few people who are prescribed opiates become addicted,” that may not be the relevant question. The true question is what fraction of people who _do_ become addicted do so after a first exposure to a prescription medication, one prescribed either for them or others. So different prescribing habits could certainly change how often opiates get abused even if most people who are prescribed them do not abuse them. Case in point: I got a bunch of Vicodin for my C-section, and when I didn’t need anymore, it just sat in my cabinet for years before I finally cleaned it out. If I had a teenager in the house, that could very easily have led to a problem. But if I was prescribed enough that very few or no pills remained, that scenario becomes less likely. Similarly, if someone who could get by with a non-additive drug is prescribed that first before an opiate, you eliminate the risk that either they or someone close to them will get hooked, even if the risk is small. I don’t think the government should be mandating this – I think medical associations, journals, and those who change best practices in a field should get a lot more aggressive about highlighting this issue so that most doctors default to more stringent prescribing habits on their own. ---

**Author:** ![docslotnick](https://yyz2.discourse-cdn.com/flex030/user_avatar/forum.fudiabetes.org/docslotnick/32/75_2.png) [@docslotnick](https://forum.fudiabetes.org/u/docslotnick)\ **Post date:** [June 3, 2017, 1:41am UTC](https://forum.fudiabetes.org/t/neuropathy-is-opioid-crisis-diminishing-access-to-pain-management/1128/10 "2017-06-03T01:41:04Z")

> [@TiaG](#): > > While it’s likely true that “very few people who are prescribed opiates become addicted,” **that may not be the relevant question** Strongly disagree. Why are the people, the vast majority, deprived of adequate pain relief because of the few who will abuse it? It goes along with a lot of product recalls. One person figures out a way to stupidly use a product and injure himself, so then nobody gets to use that product. People get hurt or fail for many reasons all the time. But why should I be deprived of something that will help me because someone else got hurt by it because it was misused? Dr. Kline gave a very reasonable way to treat the situation, but it’s not likely to be accepted because it won’t fix the problem 100% of the time.