VA researcher questions whether opioid medications are better than non-opioid drugs to treat long-term back and knee pain


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Dr. Erin Krebs is a physician and researcher at the Minneapolis VA Health Care System. In March 2018, she and her colleagues published a study in JAMA that compared the use of opioid medications with non-opioid medications for the treatment of chronic knee, hip or back pain. The results were surprising: treatment for 12 months or more with opioid medications was not superior to non-opioids when it came to improving pain-related function. And, in fact, non-opioid medications were more effective than opioids for reducing pain intensity.

VA Research Quarterly Update asked Krebs for her thoughts on the media attention her study has received, and where she thinks future research efforts will be focused.

Your study has received lots of media attention; have you begun to see any effects on clinical applications or guidelines within VA or the public sector? Do you think the results of your study are influencing prescribers?

Although it’s a bit too early for our study findings to be incorporated into guidelines, I have heard from many individual clinicians that this study has influenced their clinical practice and teaching of trainees. I expect our results to be interpreted as providing support for recent guideline recommendations. The 2016 Centers for Disease Control and Prevention opioid guideline advised that non-drug therapies and non-opioid medications are preferred for chronic pain, and the 2017 VA opioid guideline advised against starting long-term opioids for chronic pain. These recommendations were based on expert opinion and data about opioid-related harms. Our study contributes long-term evidence on the benefit side of the equation—we found no advantages to opioids that would outweigh their greater risk of serious harm. The results should reassure clinicians that following current guidelines is not likely to result in undertreatment of pain.

You have been very clear about the limitations of your study in the journal article itself and in any interviews you’ve done—that it looked only at a certain population of pain patients. Nonetheless, have you received any criticism from pain-treatment advocates who are concerned that your study may deter some physicians from prescribing opioids even when they are truly indicated? If there has been such criticism, do you believe it may have been fueled to some extent by misleading media reports that over-sold the results or interpreted them too broadly?

Misleading media reports about the study’s findings (e.g., The New York Times “Well” story “For Arthritis Pain, Tylenol Works as Well as Opioids”) generated a lot of confusion and questions from patients and caregivers. My experience with advocates criticizing SPACE (trial) is similar to what I experienced when I participated in the 2016 CDC opioid prescribing guideline development process. In both cases, social media and internet-based criticism focused on claims that the work was biased and therefore illegitimate. I suspect this type of criticism is fueled less by misleading media reports than by misleading industry-supported advocacy. We would all benefit from a more nuanced discussion of long-term opioid prescribing that acknowledges the many remaining uncertainties. We certainly know much less about benefits and harms of long-term opioids for chronic pain than we know about most other commonly used medications.

The SPACE trial compared opioid medications with non-opioid drugs. Will you conduct future studies to compare the effectiveness of opioid medications and non-drug approaches to pain management, like acupuncture or yoga?

We chose to compare opioids to non-opioid medications because this seemed to be the most direct and relevant comparison. I’m not sure a head-to-head comparison of opioids versus non-drug therapies would be as useful, since medications and non-drug therapies are typically combined in clinical practice. I’m currently leading a multi-site VA trial—funded by the Patient-Centered Outcomes Research Institute—that is testing approaches to improving non-opioid pain management while reducing opioid doses in patients with persistent pain despite long-term high-dose opioid therapy. This study, the Veterans Pain Care Organizational Improvement Comparative Effectiveness Trial, is comparing two primary care-based collaborative care interventions: lower-intensity pharmacist telecare versus higher-intensity integrated pain team care.


About the author: Erica J. Sprey is a writer in VA’s office of Research and Development. She is also the editor of  the VA Research Quarterly Update, a digital publication that is produced four times a year.

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Comments

  1. Liz    

    Dr. Erin Krebs,
    You are an Internist. What gives you the expertise to publish studies on Opioids vs Tylenol for acute and or Chronic pain. It wasn’t until you joined the VA in Minneapolis?
    Are you or have you ever Served in the Military and suffered the injuries that most Veterans that have earned the right to be treated (humanely) at the VA?
    Have you studied those in Congress, they are all old enough to suffer the illnesses, joint pain that comes with aging? Who denies their pain management? I guarantee you they do not receive their health care from those without accountability or Surveys.
    Your Study:
    This study, the Veterans Pain Care Organizational Improvement Comparative Effectiveness Trial, is comparing two primary care-based collaborative care interventions: lower-intensity pharmacist telecare versus higher-intensity integrated pain team care. What patient population did you pool from? I guarantee you, it wasn’t from the many Veterans that were just cut off their pain medications completely, starting in 2013.
    Team approach? What a joke, what a lie? We all know how corrupt the Veterans Affairs is.
    When I questioned my Primary Care provider about the Stanford, CA Pain Study and how their results proved that Opioids did in fact increase patient overall functionality; she told me we are VA, we are not Stanford. If you want pain control, go to Stanford.
    I’m surprised you are not an Anesthesiologist, aka Chronic Pain Management providers dispensing rubber stamping “Do Not Treat with Opioids.” How many Doctors or witch doctors are now profiting from this by all the Rehab Centers now? And their employees offering Heroin and synthetic Opioids in the parking lots?
    Dr. Erin Krebs, you come from an Internist background from:
    Eskenazi Health-Indianapolis
    Indianapolis, IN
    ESKENAZI HEALTH-INDIANAPOLIS IN INDIANAPOLIS, IN IS NOT NATIONALLY RANKED IN ANY SPECIALTY.

    I say again, when did you become a Specialist in Pain Management? Oh yeah, you work for VA and we all know the transparency the VA displays.

  2. Paredes Jr Marcos    

    I serms the obstacle that the VA created after so many years of prescribing opiods. I have been on opiods for the past 8 years for chronic back and joint pain. They diagnosed me with severe osteoarthritis and fibromyalgia. I feel like I am trapped. Every time I request my pain meds on a month to month basis the clerks in the pharmacy give me dirty looks and feel like they are the gate keepers of the opiods when i stop by on a monthly basis. It’s asham that I do what is required of me such as yearly opioid classes. Quarterly urinalysis and mandatory DEA contract that i am responsible for safeguarding my pain meds.
    This system needs to be fixed. I am sure I am not the only one.

    Helpless in Texas

  3. Robert L Pulliam    

    I have been dealing with pain and chronic fatigue since i came back from Desert Storm In 1991. We were never examined for anything but yet soldiers are dying from unexplained issues that the Army wont say anything about.

  4. Robert L Pulliam    

    Why does the VA constanly prescribe 500 MGs of a generic version of tylenol for pain? And then treat you like a drug addict when you ask for something stronger for knee, pain, back pain and general body Spain?

  5. Anthony Lorenz    

    800 mg ibuprofen – the Army way!

    1. John Chapman    

       I, John Chapman in 1992 was prescribed morphine for Ankylosing Spondylitis which specifically attacks the spine which in my case was very aggressive and debilitating. I had suffered with Reiter’s Syndrome which was also very aggressive since 1980. The two diseases often came together in series with each episode lasting 6 to 12 months with the episodes averaging 6 years between episodes. Each episode eroded my mobility, wasted muscles, damaged my joints further and took months to years to recover as much as was possible with each episodes permanently damaged joint bones. In 2002 I had another episode, this episode was by far and away the worst since the initial on set of the disease. I was prescribed a higher dose of morphine and Fentanyl was added. At this point I was taking 60 mg. of ER-Moriphine twice daily and 100 mcg. of Fentanyl every other day and up to 120 tabs per month of IR-Moriphine. In 2010 I had a bowel problem which turned out to be a blockage. Due to surgical blunders I ended up being operated on 4 times in 10 days, lost a couple of feet of large intestine and the illeosecal valve. I spent two months in the hospital because, while in the hospital, I contracted both C-diff and Vancomycin resistant MRSA. I was released from the Hospital without the proper Stoma type resulting in several months of 3rd degree stomach acid chemical burns. Then after 6 months the doctors performed a reversal of the stoma and reattachment of the colon and now I had the third of the nasty HLA-27B Positive triad Chrone’s disease. Just as I was beginning to recover the Reiter’s and Ankylosing reared their ugly heads. I was now under a pain management specialist and up to 60 mg. Morphine ER twice per day, up to four 30 mg Moriphine IR per day and 100 mcg Fentinal every other day. At this point the State of New Mexico, legalized medical use of marijuana andiv be yeing uncomfortable to  increase my pain medications any higher my specialist suggested that I try marijuana. Being  willing to try anything and no longer being employed by a Federal contractor I, was more than a little interested. Having used marijuana as a young man in college as the only pain killer that I had access to at that time I all ready knew that I could function just fine while doing most anything. So off I went once approved, but what I thought I knew, I quickly found out I knew all most nothing. CBDs did no exist in the old days so off I went to learn everything I could about marijuana and the research being done with it. However the point of all of this is that over the last four years I have totally weaned myself of all but the occasional opioid with the use of both CBDs and THC bearing marijuana strains. It is my personal belief that marijuana is America’s way out of the opioid crisis along with a host of other medical and mental states that it will help with.

  6. Michael Grimm    

    After 5 years on opioids I finally consulted a MD who practices Holistic medicine. I slowly lowered my dose every day for 2 months. During this time I began taking Tumeric Curcumin at the dose of 900 mg a day. After the 4th week I began taking an enzyme called Serrapeptase starting with 2 per day 3 times a day for a week. I then dropped off to a maintenance dosage of 1 tablet 3 times a day. I AM NOW OPIATE FREE……
    I stay on the Tumeric regimen and the Serrapeptase regimen. It works because both work to reduce inflammation which is the cause of pain to begin with.
    Oh and to qualify my statement while I was in the service I broke my back, neck and have had spinal surgery. BUT I AM NOT GOING TO BE USING OPIOIDS EVER AGAIN.
    When I do have pain flare ups I take Epsom Salt baths, get acupuncture and dry needling.
    I am a survivor of chronic pain and now am riding my mountain bike (on the streets).
    So for all you pain sufferers try doing something different like studying Eastern Medicine and try start doing Tai Chi…..you will become a new productive person and the FOG of opioids will not control your life.

  7. Robert Kopp    

    As a 93 yr. old disabled WWII veteran suffering severe back pain for years, I heartily endorse the conclusions of Dr. Krebs regarding the ineffective use of opiod medication. I found a 325 mg generic tablet of hydrocodone/APAP totally useless in relieving my extreme back pain. I find 3 Advil tablets are effective in, at least, reducing my back pain.

  8. PAUL TENENBAUM    

    T
    HE VA IS SUPPOSED TO HELP OLD VETERANS NOT BE AN OBSTACLE

    I AM SENDING THIS EMAIL TO THE NEW VA SECRETARY

  9. PAUL TENENBAUM    

    THE VA IS SUPPOSED TO HELP OLD VETERANS NOT BE AN OBSTACLE

  10. PAUL TENENBAUM    

    IS MY COMMENT SUBJECT TO MODERATION. FIRST “MODERATE” MY PAIN.
    PAUL TENENBAUM

    1. Ron Stapley    

      Here! Here! Everything I read here about addiction is just heartless to those in pain! Where are the alternatives that work? The alternative is to live out my life in bed. Isolated, sad and depressed. First deal with the pain. I don’t LOVE opiates either, but aspirin, NSAIDS, tylenol, and the like do nothing. I’ve taken opiates for 25 years, at least they do something. That’s better than being left without hope.

  11. PAUL TENENBAUM    

    THE WORST DECISION BY D.O.D. IN TREATING WOUNDED VETERANS WAS TO DISCONTINUE PRESCRIBING
    OPIOIDS WITHOUT CONSIDERATION AS TO PAIN FACTORS. I AM CERTAIN THAT THE NUMBER OF SUICIDES INCREASED.
    VETERANS ARE HUMAN. ONE COOKIE CUTTER DOES NOT FIT ONE VET.
    TO AVOID IMPROPER USE THE VA HAS CONTROL OF THE URINE TEST.
    I NEED THE RIGHT PAIN KILLER…….NOW, NOT WHEN A PAPER PUSHER SAYS SO.
    PAUL TENENBAUM

  12. Gregorio Morales    

    PLEASE ALLOW ME TO PARTICIPATE AS A VOLUNTEER FOR MEDICAL MARIJUANA STUDIES TO SHOW USA THAT GOD’S HERBS ARE GREAT AMERICAN MADE.

    PLEASE PLACE ME AT THE TOP OF YOUR LIST.

    PAIN SUFFERER,

    GREGORIO

  13. George T. Flint    

    In the past 25 years, I’ve asked 10 times about my dental problems which originated while serving in Germany in 1957. Got hit in face with a compressor hood while on duty. I had to see a German dentist, infection set in, after many appointments, front teeth were extracted. Partial plate made. After discharge in 1958, infection again resulting in all teeth extracted. The military says there are no records of this. Why !!! I think I am qualified for dental assistance.

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