Pain treatment

Does That JAMA Study Really Show That Advil Is Just As Effective As Opioids?

Since responses to pain treatment vary widely, it is hazardous to draw broad conclusions from a single study.


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According to Vox, a JAMA study published this week "finally" provides "proof" that "opioids are no better than other medications for some chronic pain." The results of the study are "devastating," Vox says. To whom or what is not exactly clear, but the author of the article, Julia Belluz, seems to see the study as conclusive evidence against the notion that "opioids help patients with chronic pain in the long run" or that "they are worth all that risk" of "addiction and death." Similarly, NBC News declares that the "jury's in," and its verdict is that "opioids are not better than other medicines for chronic pain." Mother Jones likewise says "a new study shows that opioids are no better than other meds for chronic pain," while Newser agrees that Tylenol and Advil "work just as well as opioids."

The JAMA study—the work of a team led by internist Erin Krebs, a researcher with the Minneapolis Veterans Affairs Health Care System—did not actually demonstrate any of that. But it did highlight journalists' eagerness to believe that no one really needs narcotics for pain relief, which reflects the widespread desire for a simple solution to the "opioid epidemic."

If opioids have no advantage over other analgesics, why prescribe them at all? Why risk "addiction and death" when over-the-counter pain relievers are just as effective? Even if we ignore the fact that the risks for pain patients are actually pretty small (and the fact that opioid-related deaths primarily involve illegally produced drugs), this study does not show what the headlines claim.

Krebs and her colleagues recruited 240 patients with moderate to severe chronic back pain or hip or knee osteoarthritis from V.A. primary care clinics and randomly assigned them to opioid or nonopioid treatment. The opioid group initially received immediate-release morphine, oxycodone, or hydrocodone plus acetaminophen. If those medications proved inadequate, subjects were treated with sustained-action morphine or oxycodone, followed by fentanyl patches if necessary. The nonopioid group initially received acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, followed if necessary by various other medications, including nortriptyline, amitriptyline, gabapentin, topical analgesics, pregabalin, duloxetine, and tramadol.

The main outcome measures were pain-related function (measured by a questionnaire, with higher scores indicating a bigger burden from pain) and pain intensity (also self-reported, on a scale of 0 to 10). After 12 months, both groups were significantly better off by those two measures. The mean pain-related function score fell from 5.4 to 3.4 in the opioid group and from 5.5 to 3.3 in the nonopioid group. Mean pain intensity fell from 5.4 to 4 in the opioid group and from 5.4 to 3.5 in the nonopioid group. The difference between the two groups was statistically significant only for pain intensity, and the researchers note that "the clinical importance of this finding is unclear," since "the magnitude was small."

In short, both groups fared about the same. "Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months," Krebs et al. conclude. "Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain."

People in pain vary widely in how they respond to medication, so the fact that opioids did not have an advantage, on average, for this particular sample with these particular types of pain does not mean they are not a better choice for some patients. The study sample was 87 percent male, and it was drawn from V.A. clinics, which may not be representative of the general patient population. The conditions were limited to chronic back pain and chronic hip or knee pain caused by osteoarthritis, so the study does not speak to opioid treatment for other kinds of pain. The initial pain intensities were middling, so the study may not reflect the experiences of patients with more severe pain.

Notably, the researchers excluded patients who were on long-term opioid therapy, which means they ignored people who had already found they did not get adequate relief from other treatments. It seems reasonable to assume that people who are currently using opioids to treat chronic pain are doing so because they think these drugs work better for them than Advil or Tylenol, and they may even be right to think that. If you exclude those patients from a study of pain treatment, you are excluding precisely the people who are most likely to get more relief from opioids.

The bottom line is that patients should be able to get the medications that work best for them. Many people with severe chronic pain report going through a long list of alternative treatments before finding that opioids were the only thing that kept the agony at bay and gave them a decent quality of life. A study like this one is utterly irrelevant to people in that situation, and to suggest otherwise is illogical as well as cruel.

Addendum: Krebs notes that the study included patients who had tried opioids or who were using them intermittently, provided they were taking fewer than 60 short-acting tablets per month. "To be eligible for the study, we required patients to have moderate-severe pain despite analgesic use," she writes in an email. "All patients in the study had tried and failed other analgesics….We excluded people with more frequent opioid use because they would need tapering/discontinuation of opioids if randomized to the nonopioid arm. Long-term opioid use causes physiological dependence (a phenomenon distinct from addiction), which generates additional clinical complexity."

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  1. OH NO! I've taken Advil...

    1. NSAIDS, including Advil (ibuprofen) are capable of increasing the risk of heart attack. If they work the same, why risk the heart attack? Opiates have few complications, if not abused! And, the risk for addiction, after receiving them for any treatment of any type of pain, is very small. Thing is, those who want to abuse them are the problem. But, they, honestly, would not fit into the statistics, if evaluated properly! Addicts can, often, be identified as abusing the drugs prior to getting them for treatment of pain! The present "opiod epidemic" is from heroin and clandestinely produced Fentanyl overdose. But, the government, and the media, love to hate us pain patients and love a good scandal!

  2. "" this study does not show what the headlines claim.""

    Nothing new there.

  3. I could have told you that NSAIDs work better for some things and opioids work better for others. For tooth pain or joint pain, Advil works better (for me). For kidney stones or a broken bone, give me some fucking dope.

  4. So maybe medical advice from Vox or NBC is no better than medical advice from the federal government?
    What a shock!

    1. No better, and usually no different.

      1. Vox seems to hold a more autthoritariaqn nanny-state progressive sentiment than NBC or the federal government.

  5. Ah, so this is the real dystopia we live in: Mother Jones concurring with Jeff Sessions. How lovely.

  6. When I had horrible wisdom tooth pain, I took a combination of Advil and Tylenol. It works quite well. Not sure about how to compare it to opiates, but it certainly dulled the hell out of some pretty intense pain.

  7. Of course it's not as effective as opioids... I've never gotten high off of Advil.

    1. When I was 18 I got all 4 of my rotten wisdoms yanked, two at a time. I was prescribed oxycodone for pain management during the week following. It killed the pain, and made me feel AWESOME. I'm not an addict, but I wouldn't turn down one at a party. And that's really what all this boils down to: puritans disliking people taking too much enjoyment from a pill.

      1. Yeah, plenty of people (I'd say most people) can manage to have some fun with prescribed pain medications without becoming junkies.

        One of the worst things about all the panic about opioids is the implied (and sometimes explicit) idea that addiction could happen to anyone, so giving the drugs to anyone is a potential problem. And that's just not the case. Some people are much more prone to addiction than others. Most people will survive having half a bottle of percocet around after they don't need it for pain anymore.

        1. I took Percocet for nearly two years, three times daily for neuralgia pain, which it only relieved some of. My issue was finally addressed properly (I had to see a neurologist instead of dentists and oral surgeons) and now, even though I get 90 per month, I take the Percocet perhaps once or twice a week for breakthrough pain.

          I should, by all accounts be an addict. Oh well, sorry to disappoint.

          1. I once took Percocet on an empty stomach, in contravention to the label. I spent the next four hours hanging over a toilet.

            1. They're really no joke, I often feel sick just like you describe.

  8. It seems to me that if you're looking for efficacy in pain management you would want to compare the same patients on the different drugs simply because it's such a subjective measure in terms of pain in the first place. A ten on the pain scale for patient A could very well be a 6 on the scale for patient B all else being equal. So, at the very least, you would want the same subjective measure with both drugs.

    I can't say if that would have produced the desired results, but the 'pain scale' is mostly bullshit so using that as your metric seems like it would also be bullshit.

    1. There are so many factors that contribute to perceived pain that I suspect it will always be a purely subjective thing. Even if you try the same patients on different drugs, their condition will have changed and their perceptions of relative intensity of pain could change too.

      And anyone's personal pain scale is likely to depend on the intensity of pain they have actually experienced in the past.
      My current 10 rating for pain is kidney stones. But I can imagine worse pain being possible.

      1. Supposedly Cluster Headaches are ten.

        1. My Trigeminal Neuralgia is.

      2. Even if you try the same patients on different drugs, their condition will have changed and their perceptions of relative intensity of pain could change too.\

        This is true, but deterioration of a condition is usually based on more than just the perception of pain (obvious not always, just 'usually') and thus can be more easily accounted for in their stats. I'm assuming these are all chronic conditions as well, which essentially means they don't 'get better' even while their pain level itself (as you point out) would fluctuate over time.

        I'm definitely not saying there's a perfect way to do such a study, it's just that it seems to me that the way they decided to do this study gave sort of biased or poor results.

      3. The bite of the Bullet Ant is excruciating. About a 25 on scale of 1 to 10.
        People have actually requested amputation because of the pain.

    2. "It seems to me that if you're looking for efficacy in pain management you would want to compare the same patients on the different drugs simply because it's such a subjective measure in terms of pain in the first place. "

      Crossover studies are much more like ideal practice. If X didn't work, you try Y. If Y works, maybe you go back to X for a while to see if the initial failure was a fluke. If it gets bad again, go back to Y.

      Trials are designed for the ease of the trial, and not to find out what's necessary to make good medical decisions.

    3. Your rating on a pain scale also depends on the duration of the symptom. After any extended period of pain you learn to downplay your reactions. So now what is a 4 for me could easily be a 9 or 10 for you. People who diddle around with these so-called "studies" are so burdened with preconceived "norms" that their methods and conclusion are virtually useless.

  9. Mainstream journalism has largely failed us all in regards to reporting on science and medicine. It's a serious problem that some in the science community are trying to address. The worst offenders (aside from clearly pseudoscience sites) are general news sites like Vox and NBC, who quite often provide no context and fail to properly represent studies. There are far better publications for science news who have true science journalists who now how to interpret studies than Vox and NBC

    1. Yup. And it's coming back to bite the media in the butt. The reason so many people on the right don't buy into global warming is that it is being pushed by the same media that rigs pickup trucks to explode in their story about how dangerous pickup trucks are.

      1. Yes, and people get a false sense of risk when there is next to none.

        E-cigarettes are yet another example of a very poorly-reported subject the last few years. No context means no realistic idea about actual risk.

    2. The first fact I wish journalists would learn is:

      The failure to reject a null hypothesis does not establish the null hypothesis.
      The failure to reject a null hypothesis does not establish the null hypothesis.
      The failure to reject a null hypothesis does not establish the null hypothesis.
      The failure to reject a null hypothesis does not establish the null hypothesis.
      The failure to reject a null hypothesis does not establish the null hypothesis.

      1. And your point?

  10. But it did highlight journalists' eagerness to believe that no one really needs narcotics for pain relief

    Jacob, normally your more perceptive than that. It's the narrative, stupid. All "reporting" now is in the service of a narrative. In this case, the narrative is IT'S THE CORPARASHUNS, MAN! THEIRYR PUSHERS 4 PROFITS!!!

    These journalos don't give two fucking shits about pain management (or really, facts). This confirms their narrative. That's all that matters.

    1. More importantly, it confirms the narrative of their readers and viewers. They've already been primed to believe that a high percentage of those who use legal opioids for an injury will become addicts.

  11. Opiods are used by Trump voters in flyover states. This is the real reason coastal elites are losing their shit over the issue. Sessions is just losing his shit because he wants the attention.

    1. Umm .... oh, never mind.

  12. My expertise in this area is limited, but it seems odd that the non-opioid side of the equation includes at least one opioid (tramadol), and several medications that target nerve pain, and are very often used *in addition to* opioids for pain management. This study also leaves out a significant reason to use opioids: side effects. NSAIDs, over long periods of time at high doses, can lead to GI bleeds, which can risk the lives of patients. Opioids don't.

    Another problem with this is that the people being studied can have pain in the same area, but caused by completely different mechanisms. Neuralgia is treated with drugs such as gabapentin, but pain due to inflammation is not. Opioids won't do much for some kinds of pain, eg: neuralgia, which are treated by other drugs. Often the pain can be from complex causes, and will need multiple drugs to help treat.

    Using this study to try to claim that other drugs are "just as effective" as opioids is strange, because I think doctors already know that. Opioids are one tool in the box, not the entire tool set. Like other issues that are hard to treat - eg: depression - each case is going to have a solution that is at least partly dependent on how the patient responds to the treatment, and experimentation will be required until the appropriate treatment regimen is discovered.

    1. Silly Pierre. How are we supposed to stoke the flames of moral panic if you show up with a bunch of facts and logic?

      1. He got facts all over The Narrative!

  13. "Notably, the researchers excluded patients who were on long-term opioid therapy, which means they ignored people who had already found they did not get adequate relief from other treatments."

    I'm always appalled to read about studies like this. Meaning, I'm appalled with most every study. I wonder if people could possibly be this dumb, or they're just this dishonest.

    1. Embrace the power of and, my child!

  14. With opioids, you still feel the pain - you just don't give a shit. Advil is supposed to alleviate pain, although it often fails at this.

  15. If you ever find yourself writing the headline "a study published this week finally provides proof of X", you know you have a problem.

    And that problem is that you're an all-credentials-no-brains, fear-mongering, moral busybody piece of shit.

  16. Aren't opioids only supposed to work with acute pain receptors anyhow?

  17. so they checked these people after a year and since they reported similar pain scores decided the medicines they took during the time in question had equal results?

    Perhaps this was addressed in the actual study, but its probably true that you could stab two people in their thighs with an 8" knife and then give one opiates for a year and the other nothing at all and that a year later their pain would have resolved to being about equal.

    That does not mean the person taking the opiates during the recovery period received no actual benefit.

  18. In addition this research doesn't address is the issue of Nsaid's side effects which contribute to almost 17,000 death annually and over 100.000 treatment related hospitalizations. I have a feeling this research was designed to please an opioids worriers and to give many doctors excuse not to get involved into effective pain management

  19. It is impossible to get addicted to, or high from, a combination of hydrocodone and acetaminophen, or hydrocodone and ibuprofen, without being killed by the acetaminophen or Ibuprofen. Both are far, far deadlier than the opioids they are mixed with for political reasons.

  20. I had a kidney stone and took Oxycodone for the first time. It didn't dull the pain the pain was gone. I had used Hydrocodone before and the Oxy was way more effective. It completely eliminated the pain.

  21. Absolute BS in my experience.

  22. The biased sample selection seems to be unavoidable in a study like this, but the authors apparently failed to highlight this limitation of their results. By studying only patients with moderate chronic pain, they also excluded the severe chronic pain patients who are most likely to get insufficient relief from Advil. But the biggest omission of this and many other studies is a discussion of the comparative risks.

    The dangers of heavy or long-term use of Advil (Ibuprofen) include heart failure, kidney failure, and liver failure. This is one of the reasons that they are insufficient for the worst pain. The dangers of _prescription_ opiates include opiate addiction, but if you are not an addictive personality type, your biggest danger is that some government official, practicing medicine without a license, will cut your supply. And if you seek an alternate source, you are at risk of overdosing due to the unknown strength and composition of the drug - but that is not a hazard of opiates, but a hazard created by the drug war!

    For someone with the wealth, intelligence, and persistence to obtain heroin and other opiates of consistent quality, it is possible to be a heroin addict and chase highs for half your life, and live to 83:

  23. Okay, I realize I've been out of medical research for a few years, but what in the world happened to JAMA? Didn't they used to be good? How in the world can they publish a study that, among other major flaws, describes as "non-opioid" a group that is given Tramadol? Tramadol is very similar to opioids, binds to some opioid receptors, has a danger of addiction, & can (& is) abused just like opioids.

    So, they're not comparing apples & oranges, they're comparing oranges to tangerines & calling them "citrus" versus "non-citrus."

    Moreover (as if that didn't render the study meaningless by itself), the study consisting of 87% males, when the majority of chronic pain sufferers are female (well, really, we all know it's just them broads being wimpy & hysterical*).

    But the "ignore facts & jump on easy answers to incredibly complex situations" crowd point to this abysmal study as "proof" of what they knew all along; that opioids are evil and anyone who takes them is too. Heck, let's ignore the fact that the majority of opioid ODs have for quite a while been users of illegal drugs like heroin & non-prescribed fentanyl.

    Facts, schmacts. Fire up the pitchforks & torches & go after legit pain patients anyway.

    *that was bitter sarcasm: I am a female who's suffered chronic pain for decades.

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