Friday, April 5, 2019

Opiates no solution to back pain

Miscarriage is common. Nearly a third of all recognized pregnancies end in miscarriage, and this number rises to 40% for women in their 40s. Many pregnancy losses happen before a woman even realizes she is pregnant. The vast majority of the time, there is nothing that a woman or her doctor can do to change this outcome. Most of these are abnormal pregnancies, destined from the moment of conception to result in miscarriage, which is nature’s way of ending them. Many of my patients attribute miscarriage to stress, or something they did, ate, or were exposed to, but this is never the case.

The good news is that having one miscarriage does not put you at increased risk for another miscarriage. Even after two miscarriages in a row, the chance of another miscarriage is only slightly higher than for women who have never had one. After three in a row, which doctors define as “recurrent miscarriage,” the chance of another miscarriage is a bit higher than for the average woman, though the chances of a healthy pregnancy are still good.

In the past, women who had recurrent miscarriage were prescribed the hormone progesterone to try to prevent another miscarriage. Progesterone prepares the uterine lining for implantation of the embryo. It also helps maintains a healthy pregnancy. Giving progesterone supplements to these women was based on the idea that their progesterone levels were too low to support a pregnancy, which could therefore contribute to a miscarriage.

However, a recent study of progesterone supplements found that they did not result in improved pregnancy outcomes. This was the first large study that compared progesterone supplements with placebo pills, which is the “gold standard” method for research studies. The good news is that many of the women in the study — nearly two-thirds — had healthy pregnancies, with or without progesterone.

It’s disappointing that progesterone doesn’t help prevent miscarriage — which can be a devastating experience, especially when it happens repeatedly. Unfortunately, some women must endure many miscarriages before they have a healthy pregnancy. This study suggests that trying again and again may be the answer, and as difficult as that may sound, it does provide hope for couples that they will eventually have a healthy pregnancy.Miscarriage is common. Nearly a third of all recognized pregnancies end in miscarriage, and this number rises to 40% for women in their 40s. Many pregnancy losses happen before a woman even realizes she is pregnant. The vast majority of the time, there is nothing that a woman or her doctor can do to change this outcome. Most of these are abnormal pregnancies, destined from the moment of conception to result in miscarriage, which is nature’s way of ending them. Many of my patients attribute miscarriage to stress, or something they did, ate, or were exposed to, but this is never the case.

The good news is that having one miscarriage does not put you at increased risk for another miscarriage. Even after two miscarriages in a row, the chance of another miscarriage is only slightly higher than for women who have never had one. After three in a row, which doctors define as “recurrent miscarriage,” the chance of another miscarriage is a bit higher than for the average woman, though the chances of a healthy pregnancy are still good. As a country, we have a weight problem. A stunning two-thirds of American adults are overweight or obese, putting them at risk of heart disease, diabetes, cancer and all the other health problems obesity brings. While there are myriad reasons we are getting fatter as a nation, one very real and simple one is that our serving sizes are getting bigger.

For example, 20 years ago the average serving of French fries was 2.4 ounces and 210 calories; now it’s 6.9 oz and 610 calories. The average soda was 6.5 ounces and 85 calories; now it’s 20 ounces and 250 calories. Our standard portions of bagels, muffins, cookies, movie popcorn, sandwiches, hamburgers, and pasta have literally doubled. We are all about super-sizing everything.

A recent study published in the journal Pediatrics suggests that this super-sizing of servings and waistlines can start really early.

Researchers surveyed the families of almost 400 2-month-olds that were only fed formula. They found that about half of them used bottles that were less than 6 ounces to feed their babies, and half used bottles that were 6 ounces or more. When they checked in with those babies at 6 months, the babies who were fed from bigger bottles had gained more weight than those who were fed from the smaller bottles — and were overall a bit chubbier (their “weight-for-length” was higher).

We feel happy when our babies eat. We like it when they finish their bottles (and we tend to prepare full ones, not half-full ones). And we encourage them to keep drinking until they do. Interestingly, another study showed that babies fed breast milk from bottles gained more weight than those fed from the breast. When we can see there is more there, we are more likely to push babies to finish the bottle — and in doing so, make feeding less about hunger and more about, well, finishing. The average 2-month-old doesn’t need 6 ounces or more at a feeding, but will often take it if pushed to do so.

The problem is that overweight babies are more likely to grow into overweight children, who are more likely to grow into overweight adults. What our minds and bodies learn early about eating can stick for a lifetime.

I am not saying that everyone should start feeding their baby less. But I am saying that we need to be more mindful and aware of how, and how much, we feed our children. A 2013 study showed that when children were given kid-sized plates as opposed to adult-sized plates they served themselves less food and gained less weight, and this is the same idea. It’s all about giving babies (and children, and adults) the amount of food they actually need — and making sure they know when they are full, and know to stop when they are full.

If parents aren’t sure how much their child should be eating, they should check with their doctor. And they should remember that not all cries mean hunger; sometimes babies are tired, need a diaper change or just want to be held. Over the last year, the general public has been inundated with a steady stream of reports about the dangers of opiates — pain medicines like codeine, Percocet, and OxyContin. The harm in terms of ruined lives and death from illicit drugs such as heroin is not news. But what is new, and concerning, are the risks of prescription pain medicines — those doctors prescribe for pain due to a range of causes, including musculoskeletal problems like low back pain.
The history of using opiates for chronic pain

Back pain isn’t a new problem either, but the history of how doctors have treated it is probably new to many. A “cliff notes” version of what changed goes something like this. Studies showed that doctors weren’t adequately treating the pain of people with advanced cancer. Research also showed that pain medicines such as opiates improved quality of life for these terminally ill patients. This realization led to recommendations that doctors monitor pain as they would any other vital sign (like temperature or blood pressure) for all their patients — and that all types of pain receive aggressive treatment, including long-term (chronic) pain, such as low back pain. At the same time, drug companies promoted new formulations of opioid medications with longer duration of activity that made it easier for patients to take on a regular basis.

The problem was that this fundamental change in practice was really devoid of any proof that it would help people better manage pain and minimize its effect on their lives. Prior reviews of the medical literature have documented that there is little evidence supporting the use of opiates for chronic low back pain. The modest benefits seen were with short-term use. The practice of using these medicines for long periods of time has not been carefully evaluated. Few risks were seen in these short-term studies, but tolerance to the effects of the medicine, side effects and dependence/addiction have become clearer with longer use.

A recent study published in JAMA Internal Medicine adds to this knowledge. Dr. Abdel Shaheed and colleagues performed an updated literature review, and their conclusions reinforce that only short-term benefits have been proven and the amount of that benefit is modest. Moreover, they examined the doses of pain medicines used in these studies and found that the pain relief people actually experienced was not that great.
Opiates for chronic low back pain carry big risks with uncertain benefits

This and prior studies clearly show that the leap to widespread use of opiates for non-cancer pain was premature. We didn’t know the long-term benefits and risks. We still don’t know the benefits, but this dramatic increase in use of pain medicines hasn’t helped people return to their previous level of activity, and rates of disability haven’t gone down. What is becoming clear are the risks, specifically rates of addiction, overdoses, and the rise of deaths attributed to prescription opiates. And people who have become addicted to their prescribed pain medicines often switch to heroin, which is cheaper and more readily available.

Now this doesn’t mean that we should stop treating pain. For many, the pain is real, chronic, disabling, and they need help managing it. And it doesn’t mean that everyone prescribed opiates becomes addicted. Nor does it suggest that opiate medicines have no benefits at all. But what it should do is give all of us pause. The bottom line is that simply taking a pill (or a handful of pills) doesn’t fix low back pain — and can lead to a whole lot of trouble.
What you can do for back pain

Fortunately, there is growing evidence for treatments that can help with chronic low-back pain, but they aren’t simple fixes in the form of pills, shots or surgery. Instead, treatments should focus on getting back pain sufferers active again and learning to manage, not cure, the pain. A range of therapies including exercise, education about how to care for your back, yoga, and mind-body techniques have been shown to help control back pain.

So what do I tell my patients? For those with chronic back pain who aren’t on opiates, steer clear. For those who are already take them, you can’t go cold turkey. Your body has adjusted to these medicines and stopping them abruptly is a bad idea. With help, people on opiate pain relievers can try to wean themselves off these medicines gradually and replace them with other treatments. This isn’t easy, but for many people it starts a long process of regaining control over the pain that has taken over their lives and can help them avoid the terrible consequences of opiate addiction.

In the past, women who had recurrent miscarriage were prescribed the hormone progesterone to try to prevent another miscarriage. Progesterone prepares the uterine lining for implantation of the embryo. It also helps maintains a healthy pregnancy. Giving progesterone supplements to these women was based on the idea that their progesterone levels were too low to support a pregnancy, which could therefore contribute to a miscarriage.

However, a recent study of progesterone supplements found that they did not result in improved pregnancy outcomes. This was the first large study that compared progesterone supplements with placebo pills, which is the “gold standard” method for research studies. The good news is that many of the women in the study — nearly two-thirds — had healthy pregnancies, with or without progesterone.

It’s disappointing that progesterone doesn’t help prevent miscarriage — which can be a devastating experience, especially when it happens repeatedly. Unfortunately, some women must endure many miscarriages before they have a healthy pregnancy. This study suggests that trying again and again may be the answer, and as difficult as that may sound, it does provide hope for couples that they will eventually have a healthy pregnancy.

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