Paper Chase Special

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Sean G., M.D. -

Doesnt address the effect on days 2,3,4,5, I suspect if all you are taking is Naproxen and you have sig back pain you will definitely be hurting for more than just your ER visit. Yeah it may pan out at 7 days because 90% of back pain that is atraumatic will resolve in that time frame....the question is how are you feeling for those first few days...its sort of silly to take the approach I'll slam u with opioids in the Ed but then your on your a week u will feel better... sure you will be in agony for a few days, but in a week....nah...Im not impressed, just another study that tells us what we already know.

Barry N. -

Completely agree with above comments. Your conclusions were way off. We are again on one of our crazy pendulum swings in Emergency Medicine. Everyone has to be treated for pain immediately because no one can ever have pain and no one can question another person's now...... everyone will become addicted (or stop breathing) by the small scripts we hand out in the ER. The comments above were absolutely to point. They first limit the study to pain that is most likely to resolve in a week, than do not test daily so that we can possibly see benefit to the patient from pain relief.
I was also floored that you suggested treating them in the ER with narcotics....why treat them....if you believe in your conclusions? Be would rather have them in pain somewhere that you did not have bear witness!
Barry N., MD

Anand S. -

Hey guys. Thanks for listening and chiming in with your thoughts. I don't think it's true that 90% of back pain resolves at 1 week. Most of the studies I've seen say that the pain could last for weeks; not just 7 days. You may suspect that patients will have significant pain at each of those intervals but we don't have data to support that. There's a dearth of evidence showing that opiates offer better pain control than NSAIDs and APAP for most any diagnosis.
As far as acute treatment of pain, I think this is a different question. We have patients coming in with migraines in whom we break the pain cycle and discharge home. Back pain and other pains may be very similar. Break the cycle and the patient may be comfortable afterwards with simply taking NSAIDs or tylenol.
As far as are we creating opiate dependency with our small scripts from the ED? We don't have the answer to that question. There are definitely publications showing an association between first scripts for opiates in the ED and subsequent scripts over subsequent years. We can't oversimplify things. There are likely patients who are more susceptible to abuse and giving them a first dose may set them down a pathway.
Bottom line to me is that if opiates demonstrate no benefit over non-habit forming medications, why use them at all? This article is just another bit of evidence demonstrating that opiates aren't as good as we think they are.

Kevin G. -

I enjoy back pain patients, once corralled into likely disc prolapse which almost all do. Pills are on the list (4 step, written and given after diagram and sit down 5min talk while they lie on the gurney) but last on the list. A diagram of a spine and description of disc fragment pushing on longitudinal post ligament gets rid of a lot of fear, and then separate talk about muscle spasm and how to deal with it (not pills) and that it might take 3-4 days to get half better.
Now and then find a facet joint on painful extension,or v rarely a likely spina bifida occulta with hyperbrisk DTRs and a story of eneuresis way later than their cohort, just to keep it interesting.
The only problem with narcotics or codeine for me is when someone asks me for it straight up and after listening examining and teaching, I explain why the answer is no they get angry and put in an official complaint. Which is unavoidable but rare.

Raoul D. -

I was surprised by your positive comments on the “Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial”. Their method is flawed. If you get a medication every 8 hours that doesn’t last 8 hours (oxycodone) and then I ask you the worst pain of the day or how functional you were, obviously that medication will not work. Also surprisingly you promote opioids in the ED, but not for when they go home, their pain intensity will not change in the next few hours…
Raoul Daoust MD MSc
Montréal Québec

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Paper Chase Special Full episode audio for MD edition 15:14 min - 13 MB - M4A