Thursday, March 13, 2014

Cochrane reviews are beautiful things.

This post is going to be a science and research heavy post so I am going to attempt to organize it in such a way that you can skip things you aren't interested in. I look at a lot of research regularly. I especially look through PubMed and the Cochrane reviews for new information on things like degenerative disc disease and treatments for chronic lower back pain. This stuff is important for me because I like to use science based treatments and don't want to waste my time and money on things that don't have evidence of safety or efficacy. To give you an idea of my process I am going to walk through what I found today on Cochrane. One of the things to note about these is that all I can really see without logging onto my school's website is a short abstract and the key results.

Opioids for the treatment of chronic low back pain. 
1. People in the treatment group reported less pain and less difficulty performing daily activities in the short term
2. No randomized controlled trials showing efficacy or safety of opioids for more than 4 months.
3. Current literature does not show an increased benefit when compared to other analgesics
4. The quality of evidence in this review was 'very low' to 'moderate' 
This study confirms something I was feeling myself. While subjectively when I was taking the opiods it felt like I could function better after nearly a year on them daily I realized that I still felt the pain but I just didn't care anymore. I am no longer on them and am taking other meds instead and I feel like I function better now since I don't have the fuzzy head I got on the opiods. I am glad I did because of what 2 says: no evidence for safety for use over 4 months. I used them a lot longer than 4 months and 3 shows that their isn't a compelling reason to pick something whose safety isn't confirmed when there are other options.

Non-steroidal anti-inflammatory drugs for low-back pain. 
1. In patients with acute sciatica (which I have) no difference was found between NSAID's and placebo.
2. there are few data on long term side effects
3. 42% of the studies were considered high quality 
I am currently taking a NSAID for my back pain and this makes me question that. The 42% at high quality is indicative that before I do anything I need to do more research into evidence for efficacy. The side effects that are known for NSAID's are scary enough (things like stomach ulcers) that I want to make sure that this is going to help. I have been on them for nearly two months and I have been hesitant the whole time but I do like to follow doctors orders and she only wanted me on them short term anyway. I have another 2 weeks on them. If she tells me to take another batch of them I am going to ask for evidence.

Herbal medicine for low-back pain
1. Devil's Claw, seemed to reduce pain more than placebo and about the same as vioxx2. Willow bark, reduced pain more than placebo and about the same as vioxx3. Cayenne in plaster form, reduced pain more than placebo, about the same as homeopathic gel Spiroflor SLR. 4. Adverse effects included mild, transient gastrointestinal complaints. 5. Trials were moderate to high quality. 6. half the trials authors showed a conflict of interest. 7. There is no evidence to show that these are safe and useful for long term use. 
I am going to preface my thoughts on this one with my personal conflict of interest here: I am a skeptic. It is going to take a lot of evidence for me to think that it's worthwhile to use an herbal product. They do have effects (unlike homeopathy) but they are not standardized or controlled enough to warrant their use. In the US there have been huge issues with herbal product contamination and even outright substitution of the products claimed. I'll leave that bugbear there though. 

As Vioxx has been removed from the market due to adverse effects these studies are not comparing to a legitimate product but beyond that of course willow bark reduced pain more than placebo. We already have something that does that, which is synthetic, derived from the bark of the willow tree, and doesn't require guessing dosages. It's called asprin. The language for devils claw is suspect to me, it seemed to reduce pain? How so? It doesn't tell me that it was statistically significant or anything really. Eh. As for cayenne I have already made my thoughts on homeopathy clear so all this tells me is that it does as well as a gel plaster would. The biggest red flags here for me are 6 and 7. conflicts of interest which will lend a study a bias towards showing an effect unless carefully controlled and with a moderate to high quality there are going to be things that will bias the data. 7 tells me that we don't know if these are safe in the long term and if you have chronic pain you are looking for something that is safe in the long term. Until that data comes in I remain, as ever, skeptical, 

Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain
1. It is unclear if TENS is beneficial in reducing back pain intensity due to conflicting evidence
2. TENS did not reduce level of disability 
I really only wanted to look at this one because I have a TENS unit and I use it when I have to sit for long periods of time, like at school. I never felt like it actually helped reduce my pain but it did help with the heightening of my pain from sitting for long periods. The effect also went away shortly after stopping the current so it's not like it was of great use but at that time even that was better than nothing. There were no indications of risk apart from the minor risk of a heat rash from the current where the diodes are placed. This review tells me that the evidence is contradictory and thus inconclusive.


I am going to leave off at this point, these were just the first few studies I looked at and I will look through studies like this every couple of weeks. Sometimes I have a specific treatment modality in mind, other time I am looking for a condition (like in this one). I use this look at the evidence as a mental map of what is going on in the various treatments so that when I go to the doctor and she asks me if I want to try acupuncture I can say no and have an evidence based reason why. I also am sure to look if there are reviews for the medications I am on or the treatment paths that have been offered to me. I am open to a lot of experimentation at this point because so many things have been tried and so many avenues of treatment have frankly been shit either due to side effects, efficacy or both.

Ideally I wouldn't have to do this, my doctor would but I completely understand. Especially for my gp there is so much going on in the literature that I don't expect her to be up to date on the most current findings. I do however expect her to know that something like acupuncture has been shown not to work, or that homeopathy is bullshit. I know that in PDX it is expected that she offer homeopathy, and indeed most doctors that have seen offer it say it in that 'please don't kill me I have to say this' voice. I have however opted not to go back to specialists because of their focus on so called 'alternative' medicine. No. I go to doctor to get medicine not have bullshit crammed down my throat. If I wanted that I would see a homeopath.

No comments:

Post a Comment