Why don’t the drugs work?

It has been reported in the BMJ that the drugs don’t work. At least paracetamol and NSAIDs (non steroidal anti-inflammatory drugs) which in this country are normally known as ibuprofen have been shown in an analysis of 35 trials to be not much better than placebo. Also they found that NSAIDs are likely to give you gastrointestinal problems – this study only looked at their use over 7 days and found a 2.5 time increase in the risk. There is also very good evidence that opioids like cocodamol and tramadol actually increase our sensitivity to pain over time.

This news will leave many wondering what now? There isn’t much point in taking paracetamol as it doesn’t work, I can’t take ibuprofen as it may give me a stomach ulcer and it doesn’t work, opioid drugs like cocodamol, tramadol, zapain and diclofenac are not recommended because they make the pain worse in time and also because of the risk of dependency and abuse. I still have disabling back pain and I don’t know what is wrong with me, I’m worried it will never get better and no one will tell me how I can recover!

These studies  look at one thing in isolation. So for example they take someone with lower back pain then offer them drugs as part of a trial, there may be a cursory history and examination to rule out red flags then, if they pass the criteria, they are in. The patients are then given a short questionnaire to get baseline results (as in how much pain they are in) and are either given ibuprofen or placebo or no treatment. Then after a period of time they will have another questionnaire designed to assess if there has been any change in their lower back pain. This is generally the way that they perform most studies on the effectiveness of chiropractic, osteopathic and physio treatment too.

The problem with this type of study is that it is simply not the way that most people receive treatment for lower back pain. Most people do not receive only one treatment in isolation; what normally happens, in real life, is that they go along to their GP or manual therapist (it really doesn’t matter which) and they should have the opportunity to give a full history where they can explain the impact of the pain as well as the pain itself – a good therapist will listen and ask relevant questions and have some empathy. Next the patient will be examined thoroughly – in most cases, in the absence of red flags, they will not be x-rayed as this will not usually add anything to the examination. The clinician will then formulate a diagnosis and treatment plan which they will discuss at length with the patient; this is important as this diagnosis and treatment pan is unique to each individual patient and should contain a lot of reassurance that the problem is not catastrophic and the pain will resolve. No treatment plan ever consists of simply taking a pill or receiving a manipulation, there is always advice on what and how much exercise should be done, sitting positions, sleeping positions, possibly dietary advice, reassurance, joint mobilisation, acupuncture, soft tissue massage, stretching, follow up exercise progressions etc. Unfortunately it is not possible to study this sort of patient encounter in traditional clinical trials and if you try to take out one part of the whole experience and study it you lose the effectiveness of the overall treatment.

Here at Cathedral Chiropractic we use a feed back system in the form of patient reported outcome questionnaires. This is a pragmatic effort to try to gather information on patients overall improvements following a course of treatment. We use the information to build a picture of the overall effectiveness of the service that we offer, it does not give us the same information as a clinical trial because we are not attempting to measure one single aspect of the overall service. We have been using this system for over 5 years and I can report that patients tell us that at 30 days after their first appointment 72% feel a definite improvement in their pain. I can also see auditing our results that we see patients an average of 5 times. A lot of our patients are being co-managed by their GPs and do take NSAIDs and even opioid medication (gasp!) prescribed by their GP as part of their overall treatment plan, they also get better.

I guess it would be lovely to work out which part of the multifaceted treatment plan is actually effective as we could then cut costs and time and dispense with all the pleasant human interactions and reassurance that current treatment protocols involve…or maybe not!

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