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Study:  Patterns of opioid dispensing and associated wage replacement duration in workers with accepted claims for low back pain: a retrospective cohort study

written by Psychosomatic Addict

Research study by Monash University –

https://journals.lww.com/pain/Abstract/2022/08000/Patterns_of_opioid_dispensing_and_associated_wage.13.aspx

The write up of the study on the Monash University website:

https://www.monash.edu/medicine/news/latest/2022-articles/opioid-prescription-patterns-in-injured-workers

It has been a while since I’ve had the pleasure of writing up a scientific study on chronic pain. Not because I believe that there isn’t a need to keep researchers honest, but because I am living with severe, daily pain, chronic illness and all the other mechanics of life – family, work, money. I just haven’t been able to find the time to indulge myself. Its good to know that researchers at Monash Uni are still cherry-picking their own data and reporting only the parts of their studies that support their anti-opioid narrative.

Case in point is this study by researchers across Monash University’s “Healthy Working Lives Research Group” and the “Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology”, recently published in the journal Pain (link above).

First author Dr Michael Di Donato says, “We wanted to better understand opioid dispensing to Australian workers with low back pain, and whether there was a relationship between dispensing patterns (duration and intensity) and the length of time spent on wage replacement.”

The study was conducted using data provided by workers’ compensation regulators in Victoria and South Australia. A sample of 9,619 compensated workers with accepted time-loss claims for lower back pain (LBP) between July 2010 and June 2013 was included.

One third of these workers were prescribed opioids at least once during their claim.  Of these, 68% received opioids short-term and at low doses, whereas 25% received opioids long term at moderate doses, and the remaining 7% were on long-term opioid therapy at high doses.

So that’s 25% plus 7% are on long term opioid therapy…that sounds bad, doesn’t it?  Wait…that’s not right. It has been reported in such a way as to sound like it’s a bigger problem than it is. 

Its not 25% plus 7% who received opioids long term at moderate to high doses, its 25% plus 7% of the one third who received opioids at any time during the study. 

So, to be clear, that’s 7% of the one third of participants were prescribed opioids at any point, which works out to be 2% of all participants of this study received high-dose long term opioid therapy. And 25% of that same third received moderate-dose long term opioid therapy which works out to be 8%.  So around 10% (2% + 8%) of the study participants received long term opioid therapy and only 2% were on high doses.

Suddenly that doesn’t sound like a crisis anymore, does it?  Because 90% of these patients did not receive long term opioid therapy. And 98% were not on high dose long term opioid therapy.

Definitely does not sound like a ‘crisis’ to me.  But if there is no ‘crisis’, no ‘epidemic’, how will Monash Uni attract more research funding?

It’s clear Monash university is using this study to promote the mythical ‘opioid epidemic’ in Australia. 

From their website they introduce the study with:

The opioid epidemic has seen governments and health policy makers around the world seek alternative methods of pain relief where possible. Yet a new Australian study has revealed that in a sample of compensated workers experiencing low back pain (LBP), a third were prescribed opioids and a small but significant proportion received the drugs long-term in either moderate or high volume.”

Sounds scary, right?  Further they say:

Guidelines recommend the prescription of opioids for LBP as a “last resort” option, with further guidance that they be used in a low dose and for a short duration. There is limited evidence that they provide clinically important benefits to pain or disability; they carry well-known adverse effects and risks including overdose, dizziness, sedation, and depression; and long-term use is associated with addiction, greater use of illicit drugs, and analgesic tolerance.

But they don’t provide references to sources of this information, or links to this ‘limited evidence’.  That’s because the reverse is true: there is plenty of evidence that opioids are both safe and effective for chronic non-cancer pain. (link to PPA page).  Including LBP.

They don’t provide links to show that opioids are bad, because ‘everybody knows’ opioids are bad, right?  Except there aren’t any studies that show that long term use is associated with addiction, what he means is dependence, which is a completely different thing.  He knows this, but is purposefully conflating the two. That’s a common tactic that anti-opioid zealots use.

And google scholar as I might, I could not find any studies that show that people who take prescription pain medications tend to move onto illicit drugs.  Infact, I found many studies that stated there was a dearth of evidence around how heroin uses started down the path of illicit drug use, and more research needs to be done. 

Of course, the media is happy to keep publishing the myth that most addiction starts with a pain medication prescription.  The trope of the ‘accidental addict’ who had some dental work done, instantly became addicted after two tablets, and started down the road to hell. Then winding up addicted to heroin and losing their livelihood, family, friends…a tragedy. And of course, its not their fault, its these terrible drugs!  No one can resist.  The usual story. And I do mean ‘story’.  As in ‘fairy story’. There is no way this can be called fact because there’s no evidence to support it.  But it’s a good headline and it gets clicks.

The only research I could find was around pain patients who were brutally forced off their opioids and a very small minority have gone to street drugs in desperation.  This would be the fault of the medical doctor who refused to treat the patient’s pain with safe, effective pharmaceutical opioids.  There are several recent studies that show tapering of opioids is more dangerous to patients than remaining on opioids long term.  But still, forced tapers are happening every day, putting chronic non-cancer pain patients at high risk of mental breakdown, overdose and suicide.

https://www.ncbi.nlm.nih.gov/books/NBK549202/

https://journals.lww.com/pain/fulltext/2022/05000/clinical_and_neuroscience_evidence_supports_the.5.aspx

But that’s not what the researchers at Monash University want us to believe, so they make stuff up and include fairy stories in their narrative, rather than research data. Monash university is a reputable research university, so of course we trust what they say.  Except we shouldn’t because they are not telling us the whole truth. 

The key part of the study that Dr Di Donato is using to further his anti-opioid agenda is this:

“The study shows that those with longer use of opioids at both moderate and high volumes recorded the longest duration of wage replacement, with a median time off work approaching 2.5 years. “

Meaning those who were on long term opioid therapy and on higher doses took the most time off work.

And from this Dr Di Donato has drawn a conclusion that is completely unsupported by the evidence – that opioids are to blame for this longer period of work, rather than the obvious conclusion: more severe pain! 

Dr Di Donato states:

“In the context of other evidence, our research again demonstrates a relationship between long-term opioid use and minimal improvements in pain and functional measures and potential for harmful adverse effects in those with LBP.

This research shows no such thing! 

For me, the immediate conclusion I draw, the logical conclusion that anyone with a grain of intelligence (and no bias) will draw is that people who are on higher doses of opioids and for longer durations have more severe pain. Is that not the most logical conclusion?

This can’t be proven, because there is no data about which medications people were taking, what their doses were and what severity of pain they were experiencing.  Hard to believe, I know. These would be very important data without which I submit this study is completely meaningless.  Utterly useless. A waste of research funding, in my humble opinion. Because it shows nothing.

It’s a very long bow to draw indeed to say that people being on higher doses for longer periods of time shows that opioids do not reduce pain or improve function. 

People with more severe pain have lower function and higher rates of disability. Opioids are not magical pills that fix everything. But they do improve quality of life, reduce pain and improve function. Those with severe pain conditions, disabling pain conditions, may not gain enough function from opioids to return to full time work.  But that does NOT mean that opioids are not effective! If a person’s pain starts at a “9” every day, if opioid reduce that to a “7” for at least part of the day, then that person will be grateful for those few hours of pain relief. However, they won’t be able to return to work full time. Perhaps part time. But again, this study didn’t examine any of these issues. This study is a blunt instrument, a hammer, when we need a whole toolbox and a lot more information about the problem to even properly diagnose is, let alone make broad, sweeping statements like “long term opioids are ineffective for chronic pain”.

It is impossible to draw any conclusions about the efficacy, or otherwise, of any opioid medications from this study because they didn’t bother to ask the participants about the severity of their pain, and if their pain was improved by opioids. This data was not captured, therefore it is disingenuous and, in my opinion, deceptive to try to draw any conclusions about opioids at all.  The data is simply not there.

In fact, the study specifically states:

“Without controlling for pain severity, these results offer limited evidence that opioids lead to longer wage replacement duration. Further research controlling for pain severity, psychosocial factors, and recovery expectations is required to confirm whether the relationship between opioid dispensing pattern and wage replacement duration is causal in nature.”

The text of the study itself is saying exactly what I concluded from reading the data: without knowing the pain severity, this study is meaningless. NO conclusions can be drawn about the efficacy of opioid pain medications if the researchers didn’t bother to ask about the participants pain levels!

Dr Di Donato, as the lead, probably wrote these words in the study conclusion. Yet he reports on the study with an entirely different conclusion, therefore his ethics must be called into question.

Further problems I have with this study is they don’t tell us which opioids were dispensed; were they weak opioids or strong opioids?  They say nothing of dose except for ‘high volume’, ‘moderate volume and ‘low volume’.  Nowhere do the authors define these terms. Is ‘high volume’ 30mg of oxycodone? or 30mg of codeine?  We have no idea. 

Dr Di Donato knows this because he is the lead in the study. Yet he is giving quotes that he knows are false, and not supported by any evidence. And this study will be reported in the media, and Dr Di Donato will be quoted saying that opioids are not safe and not effective.  No one will read the original study, just Dr Di Donato’s unethical and false conclusions, and his massaging of the data.

Is this how science should work?  Is this the kind of person who should be researching opioids? Or researching anything? Dr Di Donato clearly has biases, no compassion for people living with severe, daily, disabling pain, and for whatever reason he is misrepresenting his own data and lowering the standards at his own university.

Most offensive of all, he further states:

“As a result, we urge stakeholders to adopt strategies that reduce long-term opioid use, and build upon recent progress in this area. Potential strategies that have shown promise in other countries include financial disincentives around opioid prescription, more education to prescribers around the drawbacks of opioids and benefits of alternatives, and greater monitoring of opioid use.”

He has drawn a conclusion that his data does not support.  He is using this study to demonize opioids, and further discriminate against people who live with high impact chronic pain, i.e. disabling pain.  The people who are amongst the most vulnerable in our community. People who are already highly stigmatized, under treated, and who have had their opioid pain relieving medications taken away based on rubbish studies like this.

Dr Di Donato and his ilk are contributing to the forced tapering of chronic non-cancer pain patients off the only medications that give these people some quality of life, so that he can get a PhD.  Its deeply offensive to find this study does not support his statements, or his conclusions, and his work should be discredited, as he himself should be.    

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