Over-the-counter meds better at pain treatment than opioids, new study finds

Powerful and potentially addictive opioid drugs — often the go-to medication by doctors treating chronic pain —are actually less effective than common over-the-counter remedies such as Tylenol or prescription strength topical analgesics, according to a new study.

Dr. Erin Krebs, a physician and researcher at the Minneapolis Veterans Affairs Health Care System, said the findings of her study raise troubling questions about overprescribing opioid medications as the nation continues to stagger under addiction and overdose deaths.

“We simply found no benefit,” said Krebs, lead author of the study. “We already know opioids have more risks. You at least want to get some advantage.”

Her trial tracked 240 patients from VA clinics in the Minneapolis area who were being treated for moderate to severe back pain and hip or knee arthritis.

Half were given opioids including morphine or generic forms of oxycodone and hydrocodone-acetaminophen. The active ingredient in oxycodone is found in Oxycontin, Roxicodone and Percocet. Hydrocodone is found in Vicodin.

The other half of patients were given non-opioid medications.

At the end of the year-long trial Krebs reported “treatment with opioids was not superior to treatment with non-opioid medications for improving pain-related function.” In fact, in some instances, those who used non-opioid treatments actually reported feeling less pain, the research showed.

Her research, thought to be the first to look at the effectiveness of opioids in treating long-term chronic pain, was published this week in the Journal of the American Medical Association. It is already raising eyebrows.

“I think it has a lot of implications,” said Katharine Neill Harris, a fellow in drug policy at Rice University’s Baker Institute of Public Policy. Although the sampling was small, “the results should be taken seriously,” Harris said.

At the very least, the study shows a pressing need to look at the way opioids are being prescribed — and for what, she said.

By the numbers

Officials at the Centers for Disease Control and Prevention have said the United States is seeing the highest drug overdose death rate ever recorded. In 2016 there were 42,000 drug OD deaths involving opioid prescribed painkillers. That’s 116 people dying per day.

And while Texas has not seen the ravages of some other states such as Ohio, West Virginia or New Hampshire, it has been flagged as showing a “significant” increase in drug overdose deaths, climbing from 2,588 deaths in 2015 to 2,831 deaths in 2016, according to CDC data.

On March 1, Dr. Anne Schuchat, acting CDC director, tweeted that the amount of prescription opioids now being prescribed was “three times as high in 2015 as it was in 1999 — enough for every American to be medicated around the clock for three weeks.”

That fact grieves Krebs. “This entire thing was preventable. This did not need to happen,” she said of the opioid crisis.

Schuchat cited further disturbing statistics on Twitter. “In 2016, for every one person who died of an opioid overdose, there were 41 people living with a substance use disorder involving prescription opioids,” she wrote.

While Krebs and others said opioids have an important place in today’s pain management, “we’ve been far too cavalier.”

Anything that hurts

When she was in medical school, Krebs said opioids were reserved for very specific use including short-term pain relief after surgery, for cancer treatment, or for end-of-life care. But by the time she graduated in 2003, the powerful, highly addictive medications were being used “for anything that hurt.”

She said she assumed there must be new scientific research to warrant such a change. So she went looking for the proof — and found none.

Instead, the change in procedure appeared to correspond with the enormous push in the marketing of opioid painkillers by the drug manufacturers, Krebs said. Ads appeared in medical publications and hard-sell tactics were employed by sales representatives visiting time-strapped doctors. In each case, the drugs were said to be safe for more routine treatments as long as instructions were followed.

Krebs said she also noticed geographic variations. When she left her residency in Minnesota for a research fellowship in North Carolina she found that opioid prescriptions were written far more commonly in her new location. That reignited her curiosity.

She launched her study in 2013 with eight other researchers affiliated with medical schools, the VA and public health institutions. The study was completed in 2015.

The results, she said, cannot be explained away as the opioid treatments losing effectiveness as the body builds a tolerance. The patients were checked at three-, six-, nine-, and 12-month intervals. “The opioids never looked better than the non-opioids,” Krebs said.

She did say that among those not using opioids, some patients had to try different medications until they found one that worked. But Krebs stands by her conclusion and urges the medical community to get more creative in prescribing medication, especially for chronic, long-term pain.

The Pharmaceutical Research and Manufacturers of America, an advocacy association for drug makers, did not comment directly on the study or its findings but said in an email statement: “We support improving access to a range of treatment options, including non-opioid treatments for pain, to help patients access the approach that is right for them.”

In addition, the pharmaceutical trade association pointed to its policy position paper on combatting the opioid crisis which recommends limiting the number of days that potentially addictive drugs can be prescribed, except in certain medical circumstances, and a prohibition of them being dispensed in doctors’ offices.

A dangerous cycle

The VA study findings come as no surprise to Lori Fiester, clinical director at Houston’s Council on Recovery.

“It’s something we’ve known in the industry for some time,” she said. Opioids are not always the most effective at chronic pain management, but they are widely prescribed anyway, she said. “This is a business,” she said. “The bottom line is the dollar, not the patient.”

The pain killers are now deeply ingrained in the nation’s medical culture on both sides of the prescription pad. Patients demand relief, but as they take more and more of the drugs, their bodies build a tolerance which in turn means they crave even more.

Fiester said she has seen that cycle in her own life, too.

“The first choice were the opioids,” she said when she sought treatment for terrible migraines. That worried her because family members had struggled with addictions and she didn’t want to take any chances. But the pain was crippling, and she, like most people, wanted the most powerful thing out there to stop the pain. So she set aside her concern and filled the prescription.

In the end, the opioid did not work, she said. What finally eased her pain: Excedrin Migraine.

jenny.deam@chron.com