Behind the headlines - Opioids for chronic pain and how pain researchers cherry pick the data to demonize opioids

How scientists lie and misrepresent the data to make us think that opioids are not safe and effective for chronic pain

After my last newsletter, where I wrote about a large, recent Australian study that shows opioid addiction is rare in people being treated for pain, I received a fair few comments from people who quite rightly state that the vast majority of studies show opioids ARE addictive.   So why would I believe this one?  And what about overdose?  That’s still an important factor. And all of the other serious side effects that opioids cause.

And I say to those people, have you read the actual studies?

I have this hobby of reading studies on opioids and chronic pain and finding the flaws. I’m not a scientist. I never completed a degree.  But I can read and I do have common sense.  And to be honest, the flaws are so very obvious, it does not take a genius to find them. They’re staring you in the face.

Some of the studies I read are outright disgusting. The researchers clearly have no ethics, and no moral compass either, because they are cherry-picking their own data, and creating a false narrative with their chosen headline and conclusion.

It cannot be accidental.  Or incompetence.  These are intelligent, educated people.  Its deliberate. It’s by design.

It would be laughable, how blatantly they get away with this.  But people’s lives are being destroyed by this behaviour. My life has been destroyed by this kind of ‘science’.  So…I’m not laughing.

These scientists don’t care that they are ruining lives with their lies.  All they care about is their careers.  Which should be toast.  Unethical people with no professional standards should not be employed as researchers.  Maybe they shouldn’t be employed at all.  At least until they learn some humanity.

But I’m just a patient. Not a scientist, no degree. No one is going to listen to me.

But I will write, anyway.  I will continue to advocate, anyway.  And I will continue to educate, anyway. 

And my message is this:

Please, PLEASE…READ the study. Don’t trust the headline. Headlines lie.  Headlines are carefully chosen as a strategy to convince time poor doctors that they should not prescribe opioids.  Scientists are cherry-picking their own data and lying about their own results, all to demonise opioids.

I have many examples.  Starting with this one.

It’s another Australian study.  (Australia has some great scientists and it has some REAL duds).

It was published back in February 2022, and the title of the study is:

“Efficacy, safety, and dose‐dependence of the analgesic effects of opioid therapy for people with osteoarthritis: systematic review and meta‐analysis”

And the conclusion?

“Opioid medications may provide very small pain and disability benefits for people with osteoarthritis, but may also increase the risk of adverse events.”

Fine.  That’s pretty mild-mannered.  Personally, I am instantly doubtful that opioids provided only ‘small’ pain and disability benefits, because my lived experience tells me opioids are extremely effective pain relievers.  I know this is not true for everyone, but it’s true for most. That’s well established.

And I also know that the lead author, Dr Christine Abdel Shaheed, is notorious for producing low quality, highly biased, studies designed to demonize opioids.  She has a reputation, you might say.

She’s very media savvy, and her goal is always to get a sensationalist headline in the popular news media.  No doubt this enhances her career prospects.  Because she’s very prepared to lie and make shit up, just to get that headline.

The study generated a LOT of media headlines. Always the goal.

In The conversation:

Opioids ease osteoarthritis pain only slightly. Their deadly risks need to be weighed against any benefit

In The Sydney Morning Herald:

Opioids give osteoarthritis sufferers small benefit but greater risks

Sounds like opioids don’t do much for pain, but have serious risks, right?  Deadly risks, even. That’s because that’s what Dr Christine Abdel Shaheed wants you to believe.  

But that’s not what her study showed.

She’s only telling you half the story. The half she wants to promote.  Selective reporting.

Much worse is that the Royal Australian College of General Practitioners (RACGP) and the Australian Medical Association’s (AMA) Insight magazine also picked up the story. These are sources that GPs and other doctors use to guide their prescribing.

And they’ve just been told do not prescribe opioids for osteoarthritis pain.

These are those headlines:

This is the RACGP

Opioids ease osteoarthritis pain only slightly: Research

Their deadly risks need to be weighed against any benefit, according to the authors of a new Australian study.

‘Deadly risks’ again. Clearly that phrase was fed to all the journalists involved.

And Insight magazine goes one big step further and says:

Stop prescribing opioids for osteoarthritis, say experts

It actually tells doctors to stop prescribing opioids.  On the basis of this systemic review, of ‘all the evidence’.

Here’s the study itself

https://www.mja.com.au/journal/2022/216/6/efficacy-safety-and-dose-dependence-analgesic-effects-opioid-therapy-people

Published in the Medical Journal of Australia.  

First, let’s examine the quality of the evidence.  It’s a systemic review/meta-analysis.  A systematic review summarizes the existing, published research on a particular topic, in a methodical, rigorous, manner.  It’s basically a study of all the existing evidence for a specific question, providing a summary conclusion.

Why do systemic reviews?  Given the enormous amount of research on any given medical topic, it’s impossible for clinicians to keep up with all the latest data or every study. Systemic reviews are meant to review all of the available information, in a very specific way, to answer a very specific question.

Which sounds great. But there are several steps in completing a systematic review. These include developing the clinical question, searching for all available literature, study selection, assessment of study quality, data extraction, data analysis, interpreting the results, implications for practice and further research, and finally publishing the review. 

At any of all these steps biases can come into play. 

Sometimes the data is cherry-picked to show what the study authors want it to show.  Sometimes the study selection itself is biased.  Sometimes the data is of very low quality.  Sometimes the authors only select the studies that support the result they want to “prove” and exclude those which don’t.  And sometimes the authors only report on the parts of the study that support the intended conclusion and don’t mention the parts that don’t.  Systemic reviews are complex, and sometimes the review is just poorly done.

Back to the study.  Every study has limitations, and they are generally declared.  Immediately I can see that this systemic review is mostly using evidence that is “low” or “very low” quality.

Only ONE study is of high quality. 

Out of 21 studies listed, ONE is high quality, nine are moderate quality, and 11 are low or very low quality.  The majority are low or very low quality.

What makes evidence low quality?

Studies can be rated either “high”, “moderate”, “low” or “very low” quality.  There is a criterion that researchers use to rate the quality of evidence.  It’s called Grading of Recommendations, Assessment, Development and Evaluations or GRADE.  Studies are assessed for poor quality design, bias, inconsistency of results, imprecision and publication bias, and rated accordingly.

All of the studies used to draw conclusions in this study on pain relief and quality of life are of low quality.  Even worse, the studies used to draw conclusions on safety and serious side effects are of very low quality.

Would you use low or very low-quality evidence to make decisions?  Any decisions? If you’re buying a new car and it’s rated as low or very low quality in all its reviews, would you buy it?  I doubt it.

More importantly, do you want your doctor treating you based on low or very quality evidence?  What if you need heart surgery. Or brain surgery.  Do you want the surgeon who uses low-quality evidence to guide their practice?

No, you’d look for the surgeon who only uses high-quality evidence to guide their treatment decisions.  That’s how science is supposed to work.  You would not want any medical treatment decisions made based on low or very low-quality evidence.  Not when your life is on the line. That’s pure common sense.

Low or very low-quality evidence means more research is required and low-quality evidence should not be used to draw conclusions that guide treatment decisions.  Even moderate evidence states that future research may change the result, and therefore is not reliable.

So WHY bother doing a systematic review when the majority of the evidence is low or very low quality?  When only ONE study is of high quality?  What do we gain here, as patients?  Well, nothing. In fact, patients are harmed by this study, and all others like it.

What does Dr Abdel Shaheed gain?

The cynic in me says the only reason to use low-quality evidence and publish is to get the media headlines.  To raise her profile and boost her career.  She is safe in the knowledge that journalists are unlikely to read the entire study.  Journalists will look at the title and conclusion, do a quick interview with the researcher, publish some pre-prepared quotes from the press release and BAM! We have more evidence of the perils of opioids.  Headlines, clicks…mission accomplished.

Everybody wins…except chronic pain patients. In this case, osteoarthritis patients.

Simple as that.

While we’re speaking about quality though, lets look at bias. 

In the supplementary guide, there were 36 studies in this table, and 34 were listed as having a HIGH risk of bias.  Only one has low risk, and one was unclear.

What is the point of using studies that have a high risk of bias? Bias means we can’t trust the study. Which means, we can’t trust this systemic review. It’s based on highly biased, low to very low-quality data.

Which is the most important point about systemic reviews.  If you choose low quality studies, you can’t finish up with a high-quality systemic review.  And if low to very low-quality data is all you have, why waste time and money on a systematic review?  The study adds nothing to scientific knowledge.  It’s an appalling waste of resources.

Its nothing but a PR exercise. 

The only reason to do this review was to get media play.  To get the headline that says ‘don’t prescribe opioids for pain’.  Which they achieved.

And because of this study, and all those headlines, including in medical publications that SHOULD KNOW BETTER than to publish this tripe, people who are suffering severe pain from osteoarthritis will be given paracetamol. Or an nsaid, if they are not contraindicated. 

Their osteoarthritis pain will NOT be treated with the most effective medication, because Dr Abdel Shaheed did not report on her study accurately. NOT ONE media article mentioned the most effective pain reliever found in the study.

Which was…an opioid and a simple analgesic in a combination medicine.  Specifically, codeine with ibuprofen and low dose oxycodone with acetaminophen.  These medicines gave a reduction in pain of GREATER than 30 points, or a LARGE effect size. 

But nowhere is that reported in the media, not one of these articles mentions it, because the authors did not want this reported on. So they didn’t tell the journalists. And the journalists didn’t read the study.

And here we are.

In this study, pain scores were rated out of one hundred.  A reduction in pain scores of anything less than 10 points was rated as a “very small” improvement, 10-19 points was “small”, 20-19 was “moderate” improvement and a 30 plus point reduction was rated as a “large” improvement in pain.

Nowhere in their press did the authors mention the truth – that combination medication of an opioid and a simple analgesic gave BY FAR the best pain relief for osteoarthritis.  

These combination opioid medications were the ONLY medicine that gave a large reduction in pain.  But they buried this truth because they wanted to report that opioids have only a very small effect on pain. 

This is the direct quote from the study:

“…combinations of low dose opioids with simple analgesics may have beneficial synergistic effects. For example, the 95% confidence intervals for the pain relief achieved by low dose codeine with ibuprofen and low dose oxycodone with acetaminophen included large effects (more than 30 points). “

And what did Dr Abdel Shaheed tell the media?  In every media article, Dr Adbel Shaheed says they:

 “discovered the actual benefit of opioid painkillers for treating osteoarthritis specifically was far less than previously thought.”

And also:

“Our findings indicate that opioids provide pain relief similar to that of paracetamol and their benefit is almost half that achieved by NSAIDs.”

But this is not true. She just neglects to mention the truth, that an opioid combined with paracetamol or an nsaid provides excellent pain relief for osteoarthritis.

This is truly egregious fraud and utterly contemptible.  

Dr Abdel Shaheed did not report accurately to the media.  She did not write an accurate ‘conclusion’ to this study.  She cherry-picked low to very low-quality data, and selectively reported only what they wanted to report. 

Is this how science is done now?

This is so deceptive as to be criminal to my mind.  Unethical does not cover it.  A lie of omission is still a lie, and this is the worst kind of lie.  It is purposefully obscuring the benefits of opioids for osteoarthritis pain and reporting the exact opposite of what the studies showed.

That’s unforgivable. Because that leads directly to patient harm.

Added to that, Dr Abdel Shaheed focussed heavily on the ‘adverse events’.  She is reported in the Sydney Morning Herald as saying the adverse events in this study were “dizziness, nausea, vomiting, as well as sedation.”  Yet she continues on to say:

“We also know the risk of long-term dependency, overdose and death are also factors in opioid medicine, especially with long-release forms which are often prescribed for osteoarthritis patients.”

But her study did NOT show any of these serious adverse events!

Her comments are extremely pejorative, meant to imply that this study found dependency, overdose, and death were common adverse events. 

In truth, there were NO instances of long-term dependency, no overdoses, and no deaths reported in any of the studies.  Which must have been inconvenient, but Dr Abdel Shaheed still found a way to insert them into the media reporting and imply they were a major issue found in the study.  This is (again) extremely deceptive and unethical. 

A more factual conclusion to draw from this study would be that dependence, overdose and death are exceedingly rare, because they did not occur at all in this systemic review and meta-analysis.  But that does not suit the authors, and the media’s, sensationalist, anti-opioid narrative, so this very obvious conclusion is omitted.

If you read the study and all of the supplementary materials you will find that the actual adverse events that were evaluated were constipation, nausea, vomiting, dry mouth, diarrhoea, fatigue, pruritis (itching), somnolence (sleepiness), dizziness and headache.  In the reporting they have replaced “somnolence, which is sleepiness, with “sedation” which sounds much more scary, don’t you think?

All of these “adverse events” are extremely minor, which points to opioids being safe and well-tolerated. But again, the authors chose not to say that, instead spitting out that old chestnut about addiction, overdose and death.  Which the study DID NOT find. Fearmongering. Unethical. Unprofessional conduct.

Is this what we accept from our scientists?  It’s not exactly a little white lie, is it? All of it is lies.  All of it is made up.  Pre-determined conclusions paid for by government grants under the guise of ‘research’.

I read somewhere that 85% of research is wasteful.  This is way worse than wasteful.

I know, I’m repeating myself.

What matters is that doctors will use this study to guide their prescribing.  And they will not prescribe opioids.  Because the media coverage, especially from the RACGP and the AMA, told them not to.  And people suffering severe osteoarthritis pain will continue to suffer, needlessly. Their pain could be safely and effectively treated with an opioid pain medicine, allowing them to live more functional, active lives.

How many lives has Dr Abdel Shaheed ruined here?  That’s not an overstatement.  I am NOT exaggerating.  When people live with severe, untreated pain, they become sedentary, because tits too painful to exercise.  Living a sedentary life leads to a long list of serious health conditions, including potentially obesity, diabetes, heart disease, even cancer…and earlier death.   Not to mention depression from being in constant, severe pain and being unable to live a functional life.

How does Dr Abdel Shaheed sleep at night?  Has she even met a person who lives with severe pain?  Does she have any idea what that’s like?  I doubt it.  But this is, again, why every research team that is studying pain MUST have patient representatives as part of the team.  So that these researchers can get to know these people. And have to look them in the eyes while they are working to ruin their lives.

But I digress.  There are more deceptions, more sleight of hand, more flawed conclusions drawn from the data, ignoring the more obvious conclusions.  The study states:

 “As many as 25% of people with osteoarthritis who commence opioid analgesic therapy are still taking them one year later.”

The authors imply that this means patients are addicted, despite this systemic review finding no evidence of dependence.

The authors of this and all similar studies on ‘persistent use’ stubbornly ignore the most logical reason that a patient would continue a therapy – that is, that they are benefitting from that therapy. 

In this case, if a patient is still taking opioid pain-relieving medications a year later this would be strong evidence that the opioid pain medications are providing pain relief and/or improved quality of life.  If the medication were ineffective, the patient would cease taking the medication.  It is also good evidence of safety.

But again, this most logical conclusion is not reported anywhere, in favour of myth building and playing into fear-based anti-opioid rhetoric.

Unfortunately, it’s clear that some researchers are inherently biased and massage their data to support their pre-determined conclusions and they are not above selective reporting to “prove” their point.  Cherry-picking the data and only reporting on the part of the study that supports the idea you want to promote, may not be outright lying, but it is obscuring the truth.  In science and in life, most would agree that this is deceptive and unethical.

Now, thanks to Dr Christina Abdel Shaheed, people with osteoarthritis who are suffering severe pain, will receive substandard care. Their pain will not be treated effectively.  Because Dr Christine Abdel Shaheed does not care about patients, or their pain or their suffering.  She cares about generating anti-opioid headlines and building her career.

She’s not a medical doctor. She doesn’t have to look into the eyes of the people she is hurting with her fraud.  She’s a researcher. A scientist. All care, no responsibility, for the thousands of people who are now NOT being treated for pain with the most effective medication available, with the safest medication available, who now have to suffer and endure severe pain.  For no reason.

I’m a strong proponent of science because the scientific method is the best method we have to increase our knowledge.  Science is fluid and constantly being updated and built upon. Old ideas are sometimes discarded when we learn more.  But science can also be manipulated, and statistics can be massaged in ways to say whatever a clever statistician would like them to say.  As the saying goes there’s “lies, damn lies and statistics”. 

And science is done by flawed human beings who sometimes have an axe to grind, and ego to salve and/or a vested interest in a specific outcome.  Flawed human beings can be manipulated, or they can push their own agenda, or they may just be not very good at their job.

In every case, that leads to patient harm.

Thousands of chronic pain patients who have been taking opioids to manage their chronic pain for years, or even decades, are now being force tapered off their opioid pain medications because of unethical studies like this.  But patients’ voices are not being heard, lived experience does not matter and every day more patients are being force tapered off safe and effective pain relief, forced to suffer unnecessarily.

Unethical scientists are causing patient harms.  And media reporting allowing this to happen.  The AMA and RACGP are not doing their due diligence and are publishing low quality science.  Time poor GPs will read these articles, and NOT the source study, and will deny people access to safe, effective pain relief. 

Thankfully there are many excellent doctors out there who have years of clinical experience with real-world data, who know that opioids are a safe and effective treatment for some patients who live with severe chronic pain.  These doctors continue to care for these patients, monitoring them and prescribing appropriate pain relief for severe, daily chronic pain despite ever-increasing pressure not to do so. I am incredibly grateful to these doctors, and I am gratified that you will find some of them in the comments section of the Insight website, decrying the idea that opioids are not safe and effective.

These doctors know, from many years of clinical experience, that opioids are extremely effective and very safe in the right patient. 

And for everyone who says:

“But the science says opioids are BAD!”

Have you read the science?  Not the headline, not the oh-so-brief conclusion, have you read the whole study?

I hope that you will be inspired to, in the future. And never, ever blindly believe the hype, the headlines.  I have plenty more examples of this kind of ‘science’.  And I’ll be writing up more of these studies.  Because Dr Abdel Shaheed is still employed, despite her negligence and lack of ethics.  She is still churning out studies, and her co-authors are doing same.   There is a group of ‘scientists’ at the University of Sydney who are dedicated to demonizing opioids and if that means producing low quality science, so be it. They know it doesn’t matter.   They know there is no oversight, no repercussions for lying.

They won’t face consequences for their fraudulent study and brazen lies.  Infact, Dr Adbel Shaheed wins awards.

The Institute for Musculoskeletal Health awarded her the Vice-Chancellor’s Aware for Excellent for Outstanding Teaching and Research.

“Congratulations to Dr Christina Abdel Shaheed, recipient of the Vice-Chancellor's Award for Excellence for Outstanding Teaching and Research. An amazing achievement and very well-deserved by Christina.”

https://twitter.com/msk_health/status/1598089609237663747

This was awarded in December 2022.  Apparently, we have very low standards in pain science.   What is she teaching people…how to misrepresent their research and falsify their data?

Not much more I can say about that.

Read the studies. Challenge the conclusions.  Its very sad that we can’t trust pain scientists, but we absolutely can’t.