Chronic Pain - Adjunct Therapy regimine takes a hit

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Chronic Pain - Adjunct Therapy regimine takes a hit

Chronic Pain - Adjunct Therapy regimine takes a hit


We might wonder what goes on in the minds of the doctors prescribing Celebrex, because they are a crucial link in the drug chain.

Are they aware of the controversy or the news?

Where do they get their information from?

Are they intimidated by the College of Physicians and Surgeons to the point where they would have to balance patient safety with trying to keep their job?

First, some background -

   A few years ago the medical Colleges were notifying doctors of a new regimine of drug treatment for chronic pain patients who are taking opiod painkillers such as morphine. Called "adjunct therapy", or the "multimodal approach to chronic pain", this approach involves using anti-inflammatory drugs, anti-depressant drugs, muscle relaxants, and other drugs such as Lyrica in chronic pain patients.

   The idea is that it would provide a broader approach to pain relief in these patients, and it would help the morphine work better which would in turn help avoid increases of the morphine as tolerance develops.

   I think the whole idea of adjunct therapy is pure hooey, just a way to sell more drugs for the PharmaGiants. The patient's well being, and some of their concerns, are ignored.

   The rationale doesn't even make a lot of sense - morphine is the most powerfull and effective of all those drugs, and so taking a weaker drug will not have any benefits, but all the side effects of the "adjuncts" will have to be endured by the patient.

   One part of the reasoning in the multimodal approach is to prescribe anti-inflammatory drugs, because anti-inflammation is something morphine does not do. That only makes sense if the chronic pain patient has inflammation, and many of them do not. For example, one of the most common illnesses of the chronic pain group is Fibromyalgia where muscles cramp, twitch, ache, fatigue easily... but there is often no inflammation. This is my personal experience, as it is with the other "Fibros" I know personally - no inflammation. [admittedly, "chronic pain" can mean many things, it is not only Fibromyalgia]

   Antidepressants often have debilitating side effects, and chronic pain patients are generally more sensitive to almost everything - the basis of their illness is sometimes called "hyper sensitivity" where very little discomforts are felt as strong pains - and sure enough we find that Fibros do not tolerate the anti depressant drugs very well. "Feeling like a dishrag all day" is not an improvement on their quality of life. There is no pain reduction from anti depressants when a muscle is in a full blown cramp!!

   SO ANYHOW, now there is some NEWS: Dr. Reuben, the lead author of the study that was used to approve Celebrex was found guilty of fraud this week. It was discovered that he never enrolled ANY patients in those studies, he simply wrote it up in his spare time. He told the PharmaGiants only what they wanted to hear, that Celebrex worked well and was completely safe.



   NOW the whole "adjunct therapy" , or "multimodal approach to chronic pain" idea should be reconsidered.

  Why? - this same Doctor, Dr. Reuben, was the lead author of the study for the multimodal approach to chronic pain. The FDA and the Colleges and the drug companies were all quoting Dr. Reuben, relying on his findings to justify the multimodal approach.

   I wonder if my doctor has heard about this... I wonder if I will get into trouble for posting this?



Noah Scape wrote:
The rationale doesn't even make a lot of sense - morphine is the most powerfull and effective of all those drugs, and so taking a weaker drug will not have any benefits, but all the side effects of the "adjuncts" will have to be endured by the patient.

Your logic is reasonable, except it doesn't quite work here because it presumes that all pain is the same when actually (in a nutshell), dull pain is different from sharp pain, and chronic pain is different from acute pain in those parts of the nervous system that cause it.  So for instance, cancer pain resulting from a tumour invading bone can be treated (to some extent) by anti-inflammatories because there's an inflammatory element to it.  And opioids like morphine aren't really all that great at treating the sort of sharp acute pain they're used for, because the opioid receptors tend to have more to do with relieving dull pain.

And in the spirit of being really nit-picky, morphine isn't the strongest; hydromorphone (Dilaudid), and fentanyl (Duragesic) are more potent than morphine.

But you're bang on about the difficulties of treating chronic pain: where we want to give the patients a good quality of life by treating their pain, but the problem of the side effects of drugs in the long term is huge.

That's interesting about Dr. Reuben.  He isn't the 1st scammy doc associated with Celebrex - there was the CLASS study, where the drs who wrote it violated the protocols of the study, basically tweaking its stats to make Celebrex look more effective than it really is in preventing gastrointestinal side effects from anti-inflammatories.

And then there's the whole Vioxx disaster.  Total disclosure here: I used to recommend Vioxx, which was in the same drug class as Celebrex  - I thought it was great because it was less likely to cause allergic reactions than Celebrex.  But the truth about it was being withheld.  Turns out, there were, according to one analysis I read, enough data to pull Vioxx off the market 3 years before the number of deaths mounted high enough for that to happen.

And you may have read on the news recently about the lawsuit involving the promotion of gabapentin as a treatment for neuropathic pain.  Not related to Celebrex and Vioxx, but basically there's tons of scammy behaviour around the provision of pain treatments because of all the wheelbarrows full of money to be made.


Thanks Sineed, I was hoping to hear from you.

  All pain is not the same, I agree, but that was one of my points about the problem with asking "all chronic pain patients" to be put on the adjunct therapy drug regimine. It should not be demanded by the College, just suggested. I am feeling intense pressure to be on at least three other drugs if I am going to continue to be prescribed morphine.


 I do appreciate your openness about Vioxx. See? - doctors can be fed a line from wherever they get their information from. Patients have to protect themselves against this misinformation, but we are not so empowered.

  I had asked my own doc about the Vioxx deaths, whether it was 50,000 or 140,000,  and he said that "oh no, there were very few deaths, nothing like those numbers". He seems to be in the dark.

 I asked him about "Dr. Graham", and he had no idea who he was {Dr. Graham was the FDA doc who wrote the initial report on Vioxx, where he pointed out the problems, and he was FIRED from the FDA then}.


  But WHOA!!! Whats this about Gabapentin? That is another of the recommended "adjunct therapy" drugs for chronic pain patients on morphine. I was prescribed Gabapentin for a year - whats the deal? Off label use issues? Or that Gaba is not appropriate for nuropathic pain [i.e. MY pain]?  { got links?}






Polly B Polly B's picture

Noah Scape wrote:
But WHOA!!! Whats this about Gabapentin?

Noah, I apologize profusely if I caused you any concern; you're fine.  The lawsuit was about gabapentin's lack of effectiveness in treating pain and its promotion for this "off-label" use; not about any potential for harm.  In my experience gabapentin isn't worthless and does help some people with, say, diabetic neuropathy or phantom limb pain, but its effectiveness was overstated by the manufacturer who were looking to break into the much-more-lucrative pain market with their anti-seizure drug.  The lawsuit only came into the news the past couple of weeks, but in the pharmaceutical community we've known about this for some time; you can read about how gullible doctors can be here:

During the period of this study, gabapentin was approved by the US Food and Drug Administration only for the adjunctive treatment of partial seizures, but in 38% of visits (44/115) the “main message” of the visit involved at least one off-label use.

Polly B Polly B's picture

Sineed wrote:

Noah Scape wrote:
But WHOA!!! Whats this about Gabapentin?

Noah, I apologize profusely if I caused you any concern; you're fine.  The lawsuit was about gabapentin's lack of effectiveness in treating pain and its promotion for this "off-label" use; not about any potential for harm. 


Unless any of these apply to you....


The following side effects have been reported by at least 1% of people taking this medication. Many of these side effects can be managed, and some may go away on their own over time.

Contact your doctor if you experience these side effects and they are severe or bothersome. Your pharmacist may be able to advise you on managing side effects.

  • back pain
  • constipation
  • coughing
  • dizziness
  • drowsiness
  • dry mouth
  • erectile difficulties (problems getting or maintaining an erection sufficient for sexual intercourse)
  • fatigue
  • heartburn
  • increased appetite
  • itchy skin
  • muscle pain
  • nervousness
  • runny nose
  • sore throat
  • swelling of feet or ankles
  • tremors (shaking)
  • twitching
  • weight gain

Polly B Polly B's picture

Check with your doctor as soon as possible if any of the following side effects occur:

  • abnormal heartbeat
  • abnormal thoughts
  • involuntary eye movements, double vision, or other vision changes
  • poor coordination
  • problems with your teeth or gums
  • speech problems such as slurred speech; abnormal rhythm, speed, or tone (such as sounding hoarse or "nasal") of speech; limited mouth or tongue movements; or drooling
  • symptoms of decreased white blood cell levels (which help fight infection) in the blood (such as high fever, sore throat, frequent infections, or sores on the body or mouth)
  • symptoms of depression (feeling sad; losing interest in work, hobbies, or friends; increased or decreased appetite; sleepiness or difficulty sleeping; weight loss or gain; feelings of hopelessness or guilt; or thoughts of suicide)

Stop taking the medication and seek immediate medical attention if any of the following occur:

  • symptoms of a heart attack (such as chest pain or pressure, sweating, lightheadedness, nausea, anxiety, or shortness of breath)
  • symptoms of a stroke (such as sudden unexplained numbness or weakness, especially on one side of the body; sudden vision problems in one or both eyes; sudden confusion; sudden difficulty speaking; or sudden unexplained severe headache)
  • symptoms of a serious allergic reaction (such as swelling of the face or throat, hives, or difficulty breathing)

Some people may experience side effects other than those listed. Check with your doctor if you notice any symptom that worries you while you are taking this medication.

Are there any other precautions or warnings for Teva-Gabapentin?

Before you begin using a medication, be sure to inform your doctor of any medical conditions or allergies you may have, any medications you are taking, whether you are pregnant or breast-feeding, and any other significant facts about your health. These factors may affect how you should use this medication.

Alcohol: Avoid alcohol while taking gabapentin, as gabapentin may cause alcohol intolerance that leads to an unpleasant reaction after drinking alcohol, such as flushing, redness of the face after drinking alcohol, nausea, palpitations, or headache.

Drowsiness/reduced alertness: People with uncontrolled epilepsy should not drive or handle potentially dangerous machinery. Gabapentin may cause drowsiness, dizziness, or problems with coordination. Those taking gabapentin should not do any activity requiring mental alertness or physical coordination until they determine that gabapentin does not affect them adversely.

Kidney function: Gabapentin is not removed from the body as quickly in people with reduced kidney function as compared with those who have regular kidney function. Your doctor may reduce your dose as needed.

Stopping the medication: As with other medications used to control seizures, stopping gabapentin suddenly is not recommended because of the possibility of increased seizure frequency.

Pregnancy: Do not use this medication during pregnancy unless the potential benefit justifies the potential risk. Talk to your doctor if you are or may be pregnant.

Breast-feeding: Gabapentin passes into breast milk, but the effect on the breast-feeding infant is unknown. Breast-feeding while taking this medication is not recommended unless the potential benefit outweighs the potential risks. If you are breast-feeding or considering breast-feeding, talk to your doctor.

Children: The safety and effectiveness of gabapentin have not been established for use by children. Although children 12 to 18 years old have taken this medication and reported similar side effects as adults, they should be monitored closely by their doctor. In medical studies, children 3 to 12 years old experienced some psychiatric side effects, including mood swings, hostility, hyperactivity, and thought disorders.


Other than that though, you're fine.  The medication is simply ineffective.


Those only apply if he's taking the drug - now that he's not taking it any more, he's got nothing to worry about (I was afraid when I said "lawsuit" that I'd implied he had a long-term risk of some sort).

The dizziness and the drowsiness are the main complaints.  People also gain weight on it, though many of my patients are too skinny so that's not a bad thing in those specific cases.

Polly B Polly B's picture

See in my world I would consider it a problem that I had been prescribed the drug at all.  It would piss me off that the drug was being pushed for treatment of a condition that it had never been approved for.  That my doctor was so fekking blown away by the pharmaceutical reps weekend in Vegas that he thought it would be okay to make me a guinea pig for their experiments.  That my evidence-based medicine is not only ineffective for pain, but it might also make me fat dizzy and impotent.

It would also totally piss me off if I found out my pharmacist was aware that the drug I was taking was being pushed by gullible doctors who were unaware of the misrepresentation - especially if that was not made clear to me at any time.




That's one of the reasons I don't work in retail any more, Polly; I was compelled to dispense medications that I didn't think were appropriate (yes - legally compelled).

And your concerns are a part of why that lawsuit is going forward.

As drugs go, however, gabapentin isn't all bad.  I have a couple of patients on it; they like taking it, finding it helps them with their pain, and to get through their days feeling human.  I have a methadone patient who takes gabapentin to deal with the pain suffered in a serious industrial accident 25 years ago, and he finds it helps (and he had become addicted to heroin to deal with his pain).  The drug company exaggerated its virtues, but it doesn't completely lack them.

Polly B Polly B's picture

Sineed wrote:

That's one of the reasons I don't work in retail any more, Polly; I was compelled to dispense medications that I didn't think were appropriate (yes - legally compelled).



Wow.  That's messed up.  So my pharmacist, the retail guy, has to dispense whatever the gullible doctors write up, yes?  Where's the duty to inform the patient in all that?  You suggest that while the doctors had no clue, the pharmacists were aware that the meds were being used inappropriately.  Shouldn't someone be saying something?


We are allowed to refuse to fill prescriptions if it's therapeutically inappropriate, but there's a fairly broad grey area there, and the burden of proof is on the pharmacist.  I discovered this when I told my boss I was no longer going to fill prescriptions from a certain doctor, who was a quack, supplying drugs to people with substance abuse problems.  His scripts were stupid.  So my boss called the college of pharmacists to make sure it was okay for me to do that, and they said no; I couldn't stop filling scripts because I didn't like a particular doctor (you should have seen his scripts - his writing was all quavery and shaky as if he were high as a kite when he wrote them).

So one day, I received a couple of scripts from this doctor - the usual crap, a couple receiving a couple of dozen Tylenol # 3, a dozen or so Seconal, and a handful of Valium 10 mg (sometimes the doc would add on an antibiotic to try and make it look legit, and the patient would always say, hold the antibiotic).  I can't emphasize how dumb these scripts were.  I heaved a sigh and filled them.  Ten minutes later, a cop approached the pharmacy counter saying, what did I give those people?  I said, I can't tell you; medical information is confidential.  He said, okay, and went away, returning a few minutes later with empty bottles saying, do I need to take these folks to the hospital?  The couple were caught shoplifting, and in order to avoid going to jail, they took all their pills at once.

So yeah; I don't like retail pharmacy much.


The thing about Gabapentin is not the harm it may have done to me, but about how the existence of this lawsuit supports my argument against "adjunct therapy", or "the multi modal approach" [both of which simply means "get them on several types of new pharmaceuticals so we don't have to prescribe as much plant-based medicine such as morphine"].

The revolution has to start somewhere, or nothing will change. My relationship with my doctor is one place to start, even though that is a tough nut to crack. If I could get the Doc to see the bullshit, things could change. Or, Sineed, it is more like "the doctor is a very intelligent person, they KNOW this is all bullshit but they are forced/willing to play along"?

Medical practises are human rights issues. MY body!!! My body is MY responsibility, yet I am being asked to hand it over to a doctor who may or may not be motivated by something other than my well being. Harrrrummmpppphhhh, nuff said, start the damn revolution allready!!!


Here's an update from 2007:

Fibromyalgia Treatment Update

Fibromyalgia is a common chronic pain disorder characterized by complex symptomatology and few consistently effective treatments. The purpose of this review is to highlight the recent literature from April 2005 through September 2006 involving treatment options.

Recent findings: Prior evidence suggests that medication and self-management approaches to care can improve symptoms, function and well-being in this patient population. Recent studies examining the efficacy of two serotonin and norepinephrine-reuptake inhibitors - duloxetine and milnacipran - and the anticonvulsant pregabalin are encouraging. Studies evaluating different forms of exercise continue to support the belief that increased physical activity is an essential component of any treatment plan for the patient with fibromyalgia. Three studies added to the understanding of treatment adherence. Finally, three studies evaluating the efficacy of acupuncture in the treatment of fibromyalgia showed conflicting results, but added to the knowledge needed for clinicians to have substantive conversations with patients.

Summary: Recent studies support the recommendation of a multimodal approach to treatment involving individualized, evidence-based pharmacotherapy and self-management. Treatment goals should include the improvement of symptoms, primarily pain and sleep, and the promotion of positive health behaviors with the aim of improving physical function and emotional well-being.

Basically, studies are ongoing, but there's still lots we don't know.  Medicine tries to negotiate between the patient's needs, and the doctor's knowledge.  There are lots of people like me, who try and make sure the drug companies aren't feeding us bullshit - bad science is unethical, and yeah; if it relates to medicine, it can be a human rights' issue.

remind remind's picture

Interesting details, did anyone see the Nature of Things last week end about Buddist pharmacology and medicine?


If not, do try and see it on repeat, or watch it on line, it was just excellent, and Suzki noted that fully 1/3 of our dispensed medicines are "plant" based in origins.


Well, ya, those studies found that the "multi modal approach" to Fibro is a good idea. My whole point here is that Dr. Reuben was one of the originators of that idea, he might have coined the term "multi modal approach" himself for all we know!!

 Also, I just want to make sure you are aware that patients like myself are being heavily pressured to take "those other drugs" even if we are getting sleep and adequate pain relief with morphine alone. The College can demand that if I do not comply I could lose my morphine prescription, and they are handing out fines to doctors when they do not convince their morphine-prescribed patients to take other drugs.


  PS - The BC College trimmed morphine prescriptions back by several thousand patients in BC in the past year in a crackdown that involved pee testing for the presence, or not, of morphine. That might have been a good thing, catching people who don't even take their morphine, those who are just selling it. There are problems for sure.


PPS - I saw that Suzuki program. That is an area of medicine that holds some promise for Fibromyalgia, to get at the root causes of it.  "My Chi is blocked" - I believe there is something to that approach.

 The "plant based" medicines of the PharmaGiants is not really plant based, is it Sineed? Don't they just use coal tar chemicals to mimic the plant's compounds? And isn't that why our livers get toxified from pharmadrugs?










I'd be surprised if it wasn't higher than 1/3, remind.  And thanks for the heads-up about that show; we don't watch much TV and so I tend to miss these things unless somebody tells me about them.

Though a caveat about plant-based medicines: plant-based drugs came about because plants evolved to have these protective mechanisms in the form of compounds that are poisonous to the mammals that would eat them.  Some of the nastiest poisons in existence are plant-based: think cyanide, strycnine, hemlock, deadly nightshade, foxglove, coumarins from sweet clover used to make rat poison, and so forth.

Plant poisoning:


I take Celebrex for arthritis in my fingers. Used to take Vioxx.



Noah wrote:
The "plant based" medicines of the PharmaGiants is not really plant based, is it Sineed? Don't they just use coal tar chemicals to mimic the plant's compounds? And isn't that why our livers get toxified from pharmadrugs?

Thing is, your body doesn't know if a chemical came from a plant or from Dow.  The history of a compound isn't important - that's why "natural source" vitamins are a scam.

Your liver can be damaged by poisons (see my previous post) or by too much of some things - the most common cause of liver damage in North America is too much alcohol (another totally natural substance btw).  Morphine isn't a problem.

We evolved to handle all sorts of toxins through our liver - one important enzyme system comes from a gene that may be 3 billion years old.  

remind remind's picture

perhaps it could be sineed I thought it low too, but perhaps that is just a low estimate...of not knowing all the patent compunds  until the patent becomes open and can be used for generic purposes.


Never watch  the Nature of Things, myself but flicked the TV and was watching the monks out digging licorice root, and became interested enough to watch.


So you are welcome glad to share.


remind wrote:

Interesting details, did anyone see the Nature of Things last week end about Buddist pharmacology and medicine?


If not, do try and see it on repeat, or watch it on line, it was just excellent, and Suzki noted that fully 1/3 of our dispensed medicines are "plant" based in origins.


My old family physician is now a buddist and a major practitioner of eastern medicine in your neck of the woods. It's incredible some of the things he's accomplished with the expanded medical knowledge.

remind remind's picture

My neck of the woods? ;)

This area cettainly is a hot bed of natural care and other types of medical well beings though. Much like VIsland.


Unfortunately western medicine practicioners, or those that control it, want no threats from outside their world actioning anything but their type of health care.


meanwhile they are busy allowing unnecessary masectomies and other make a Dr/pharamcist rich treatments



Yep. Your neck of the woods. Up in cross-burning country

remind remind's picture

:D  Heywood!


He obviously gave up western medicine or they would've pulled his credentials, or disallowed him access to hospitals.




Or how about this idea:
  I should be on as few drugs as possible, and if I feel morphine is working well enough for me, leave it at that.

  Chronic pain patients should not, and generally do not, expect to have total pain control... the idea is to make it tolerable. I accept that I will have some hours of serious pain every day, and all I ask is that I get occasional relief.

  In fact, isn't that "everyone's life"? All working people hurt somewhere by the end of the day, they all get fatigued, but they get relief when they get home [after supper is made and cleaned up, and the kids are in bed...]. Up and down, on and off. Thats life.

 The Doctors should be encouraging me on this, but instead I am feeling threatened by the College's agenda to have me on several drugs as fits with their "multi modal" theory [a theory that might not be supported by science, as the fraudulent Dr. Reuben was in on the creation of that idea].


And back to the flow of this thread - "Morphine is not toxic". Isn't that interesting. Addictive, sure, and the withdrawals all hell beyond waterboarding hell, but despite what the War on Drugs tells us, opiate drugs are pretty darn compatable with the human body. We even have the M U Opiod receptors!!

We have evolved this "bio-compatible relationship" with some plants, but obviously not with pharmaceuticals.

I believe that pharmaceuticals are generally more toxic than the medicines that are derived straight from plants, such as herbal medicines. Pharmaceutical research is often all about making a certain type of compound "less toxic" - they knew it worked to reduce inflammation or whatever, but it was killing the rats, so they kept tweeking it but it is still somewhat toxic and your liver has to deal with that. The history of Vioxx, etc., is like that.

Alcohol is the most common reason for liver toxicity, but in recent years there were a high number of liver failures showing up in emergency wards that were from Tylenol. In fact, Tylenol might be catching up to alcohol in numbers of liver destruction cases.



remind wrote:

:D  Heywood!


He obviously gave up western medicine or they would've pulled his credentials, or disallowed him access to hospitals.




That and they made him change his last name to 'CrazyMedicineDude'.

No, he still has full access and credentials.

remind remind's picture

Good for him, guess the powers that be are not threatened by him...or perhaps it is because there are so many non-traditional Drs in this area that hey look the "otherway"  ;)


Holy crap!!! One of the most well-regarded (or at least well-attended) pain doctors I know has made gabapentin a mainstay Rx for chronic MSK pain. Every person I see who goes to her comes away with that script -- and if it doesn't work, she way ups the dosage.

And Celebrex, too!!!

I need better advice on pain management.