Puzzling AHA Statement on Chronic Pain

Guest blogger extraordinaire Kelly Hills brings word of this story regarding the American Heart Association's new recommendations regarding usage of the class of NSAIDs known as Cox-2 inhibitors:

The scientific statement said that, with the exception of aspirin, there is now strong evidence that NSAIDs are associated with an increased risk of heart attacks and stroke. If 100 patients who have had heart attacks in the past or are at risk for heart disease take these drugs for a year, researchers would expect to see six additional deaths in this group. NSAIDs reduce fever, pain and inflammation.

The statement expressed particular concern over a subgroup of these drugs known as Cox-2 inhibitors. The only drug in this group currently on the market in the United States is Celebrex.

So far, nothing particularly novel.  Concern over the Cox-2 inhibitor drugs has grown since Merck removed Vioxx from the market in 2003, so one would presumably not be shocked that the AHA has reassessed the risk-benefit calculus related to this class of drugs and recommended that such drugs not be used as frontline therapy for chronic pain.  But the AHA went much further.  Not only did they advise against using the Cox-2 inhibitors, they recommended that physicians avoid using all medications for chronic pain:

Patients should be treated first with nonmedicinal measures such as physical therapy, hot or cold packs, exercise, weight loss, and orthotics before doctors even consider medication, said the AHA scientific statement published in the journal Circulation.

Patients who get no relief after those measures have been exhausted can be considered for drug therapy, but doctors should try drugs only in a certain order, the statement said . . . .

Umm, what? I am no physician, but moving from the premise that Cox-2 inhibitors ought not be used as frontline therapy for chronic pain to the conclusion that chronic pain patients should be treated first with nonmedicinal measures requires a host of additional inferences that are left totally unsaid by the AHA.  The seriousness of this recommendation cannot be overstated.

Though this blog is not a chronicle of my own academic pursuits, I have made no secret of the fact that pain and pain management is my central area of interest (it will be my dissertation topic, in fact).  Given that the undertreatment of pain is such a staggeringly widespread problem -- and that part of the problem is undermedication of pain -- the AHA's recommendation that medication be avoided for chronic pain patients at risk for cardiac disease is highly likely to exacerbate the problem.  This is not necessarily to condemn the AHA's position outright, but is rather to suggest that the the stakes of the AHA position are incredibly high.  One might analogize this to a constitutional law question where the court must examine whether the regulation at issue passes strict scrutiny.  By this I mean that the AHA recommendation would have to demonstrate a highly compelling interest in recommending avoidance of pharmacological treatment for chronic pain patients at risk for cardiac disease, because the consequences of such a recommendation are likely to be profound where pain is so undertreated to begin with.

Jean Jackson, among others, has extensively documented that the problems of pain management are particularly serious among chronic pain patients, who consistently report the worst, most conflict-ridden relationships with physicians.  The AHA recommendation is unlikely to ameliorate this problem.

Kelly, who suffers from chronic pain, sums it up well:

There are many ways to treat chronic pain problems, and how the treatment happens should depend on the individual scenario. While it would have been perfectly fine for the AHA to come out and say "look, there are some serious risks associated with both the Cox-2 and NSAIDs, and here they are, and this is how we'd recommend using them" - well, okay, that's one thing. But that's a far cry from recommending not how to use medication but to treat patients, and from declaring that no chronic pain patient should receive painkillers until after they've jumped through a long and potentially detrimental (without relief) series of hoops.

I cannot disagree with her.  Consider that some chronic pain patients at risk for cardiac disease are unlikely to experience much relief from their pain without pharmacological interventions (of course, there are all sorts of pain which respond well or even better to nonpharmacological therapies).  The AHA position means that such patients are consigned to suffer through their pain while the physician, who, based on the empirical evidence, is unlikely to manage their pain adequately under the best of circumstances, prescribes all sorts of interventions that do little to ameliorate the patient's pain, while all along there exists some (pharmacological) interventions that may actually be therapeutic.  The patient will suffer through this pain until the physician exhausts the nonpharmacological interventions and finally prescribes pharmaceutical therapy.

This strikes me as ethically problematic.  Thoughts?

Comments

[Kelly Hills]

...it's terribly strange to see myself quoted in another blog.

Oh. Not the thoughts you were looking for? ;-)

I'm a little less on the far side of exhaustion tonight, and I'm still irritated over the report. Given how much press coverage the problem of pain medications, prescriptions and management gets in this country, the AHA has no excuse or ability to claim ignorance about the issue. And this report is just going to make the patient/doctor conflict over treatment worse, extend (cruelly) the suffering of patients, and do absolutely zero good.

That, not 10 minutes after reading this report last night, I found another report strongly encouraging the use of NSAIDs to treat dysmenhorea is just funny.

And maybe that highlights the bigger problem here - these groups aren't working together, just like so often doctors aren't working together. Where's the coordination to make certain that recommendations don't baldly contradict one another, increasing public confusion? Where's making sure inter-discipline dialog happens? It's a larger mirror of the conflicts that happen when patients see multiple doctors and receive multiple, conflicting treatments.

[basquette]

As a chronic pain coper for years now, I feel this is pretty much (and unfortunately) par for the course. I suspect that at its roots, it's related to the unsubstantiated fears of addiction and the ill-conceived "war on drugs." It's not just apples and oranges - it's apples and fish. Or bicycles. Or something.

For me, medication absolutely saved my life. I tried those AHA standards - it took me 5 years to finally ask for pain medication, after unsuccessful attempts at everything from massage therapy to ice massage to acupuncture. Five years of my life I'll never get back. How much of my daughter growing up did I miss because I was too consumed with hurting?

[Dan]

The Forgotten Benefits of Aspirin

Almost on a daily basis, one may read about a new medication being developed or approved for the benefit of patients. At times, these announcements may praise the innovation and novelty of such drugs that are new and possibly available to all in need of it.
But it’s possible the one super drug is not new and really is a super drug. In fact, it’s one of the oldest medications available, and that would be aspirin- the first non-steroidal anti-inflammatory drug (NSAID).
Noted as ASA by doctors typically, aspirin effects have been noted for thousands of years, as the active ingredient comes from the bark of a White Willow tree, and long ago, patients with pain or a fever would chew on this bark for relief.
Fast forward to over a hundred years ago and Bayer pharmaceuticals (pronounced ‘Beier’), which is the same company that brought us heroin and mustard gas, as well as methadone. The company originated in Germany, but presently has its U.S. headquarters in New York. Felix Hoffman, seeking to develop an agent for his father’s rheumatism, was involved in the development of what is known now as aspirin. And it was a difficult task to develop this drug, as it was toxic to the stomach due to the nature of the active ingredient again obtained from the bark of the white willow tree. Dr. Hoffman and others at Bayer developed a drug that proved to be tolerable to patients while keeping the active ingredient in tact through a method of delivery developed by Dr. Hoffman’s team at Bayer. After launching the medication, aspirin was priced at about 50 cents an ounce, as at the time it was only available in power form. Soon before 1920, aspirin developed the tablet form of the drug and was then available by prescription. Regardless, aspirin was responsible for one third of sales for Bayer during this time, due to its popularity at that time.
While all drugs have side effects, aspirin is one of very few drugs that provides great efficacy and indications, with limited side effects. In fact, some of aspirin’s additional uses have been recently discovered. This may be why the New York Times called aspirin a wonder drug in the 1960s. In the 1970s, the mechanism of aspirin was isolated, which is the blockage of prostaglandins.
With Aspirin and its potential life-extending benefits:
Aspirin has been associated with decreased risk of asthma and prostate cancer in the elderly. Also, aspirin has been linked with lowering the risk of breast cancer and colon cancer as well. Aspirin is a blood thinner, and has been associated with decreasing the risk of heart attacks and strokes in certain patient populations, as the drug prevents clots. This was first suggested in the 1940s and the FDA suggested that it be the drug of choice for those who experienced a heart attack over a decade ago. Aspirin intake is beneficial for those after coronary bypass procedures. A topical formulation of aspirin was developed recently for those experiencing Herpes pain. The drug has been proven beneficial for those experiencing migraine pains. Aspirin at low doses is taken by many as a preventive drug to decrease cardiovascular incidents that may occur.
Aspirin has been the best selling painkiller since the 1950s. It is not as addictive as other choices for patients regarding pain relief in particular. It is also the most studied drug- with over 3000 scientific papers published worldwide. Also, over 15 billion tablets of aspirin are sold annually, which amounts to about 80 million aspirin tablets consumed daily by others. This amounts to over 16,000 tons of aspirin consumed during this time, or about 70,000 metric tons of aspirin a year. Over a decade ago, a study was performed and concluded that twice as many people would choose aspirin over a computer, given the two choices, because of the benefits of the drug.
Side effects would include GI bleeding if taken in large amounts, along with an association of Reye’s syndrome in children, yet both are relatively rare. Yet all things considered, clearly the benefits of aspirin outweigh any risks of the drug.
Lately, there have been issues with other NSAIDs, such as Cox II inhibitors, without full recollection or knowledge that aspirin is in fact the world’s most widely used drug, and for good reasons.
At times, something newer is not always better

“We might die from medication, but we sure killed all the pain.” ---

Conor Oberst

Dan Abshear