Once formed, habits are extremely difficult to break. It seems easier to go on as you have before and don’t change anything. This can become a serious problem when science gets in the way of the habits. If you look at the world of adverts in print and the media, you will see opioids recommended as the sure-fire drugs to use as painkillers, no matter what the pain. It carries on in the venerable tradition of the slogan, “Beecham’s Pills cure all ills”. The idea of a panacea – one pill to rule them all, as The Dark Lord of Mordor might have said – has been around since the beginning of time. This is fair game for the marketers to use when talking to the public, but the same thinking has entered the training manuals for the medical profession. Sit in lectures for student doctors and you will hear the same story that opioids are the first line of defense when it comes to moderate to severe pain. Once you have the source of the prescriptions in on the group think, the habit is almost impossible to break.
The monitoring and review process put in place after a drug is released into the market is designed to catch any unexpected side effects. If evidence of problems emerges, the FDA can require the manufacturer to change the warnings on the label or, in the worst cases, withdraw the drug from the market. But this monitoring process is not designed to catch the drugs that are ineffective. If no-one has an adverse reaction when taking it, no report is filed with the FDA. It’s safe so who cares whether it works. All this brings us to the Cochrane Collaboration. This is a non-profit group where researchers sift through and analyze existing published medical research to see whether there are any consistent patterns – what might not be apparent in one clinical trial involving two hundred participants might be identified when you compile the results from fifteen different trials, each involving two hundred participants. Two recently published Cochrane Reports have concluded that opioids should not be routinely prescribed to patients even with severe pain from hip and knee osteoarthritis.
In both Reports, the independent conclusions were that the adverse side effects outweighed the benefits and that tramadol, as the leading opioid, was no more effective than the strongest NSAIDs. The first Report consolidated the results from ten trials involving a total of just over 2,250 participants and concluded that there was little pain relief and minimal improvement in mobility. With higher dosages, one in twelve participants experienced adverse side effects. The second Report consolidated the results from eleven trials involving 1,020 participants and found little difference between the effectiveness of tramadol and the placebo. This leads to a somewhat controversial conclusion. That doctors should not routinely prescribe opioids for the treatment of hip and knee osteoarthritis. There should be a careful discussion of treatment options including weight loss, physical therapy and exercise, and a detailed explanation of all the adverse side effects to be expected. This new research does not change the general acceptance of tramadol as an effective painkiller. All it does is confirm that there is no such thing as one pill to cure all ills.