Back Pain? You Probably Worry about Taking Opioids and Only Get Moderate Relief from Them

Back Pain? You Probably Worry about Taking Opioids and Only Get Moderate Relief from Them

New research presented at the ANESTHESIOLOGY 2016 annual meeting suggests that the millions of people who take opioids for chronic back pain get moderate pain relief and they worry about the stigma associated with taking them.

“Patients are increasingly aware that opioids are problematic, but don’t know there are alternative treatment options,” said Asokumar Buvanendran, M.D., lead author of the study, director of orthopedic anesthesia and vice chair for research at Rush University, Chicago.

“While some patients may benefit from opioids for severe pain for a few days after an injury, physicians need to wean their patients off them and use multi-modal therapies instead,” he added.

The study looked at 2,030 people with low back pain who completed a survey about their treatment.  Nearly half of the people who completed the survey (941) were taking opioids at the time.  They were asked about how successful the opioids were in relieving their pain and only 13% said “very successful.”  Many (44%) said opioids were “somewhat successful” and 31% said “moderately successful.” The remaining 12% said opioids were “not successful” in managing their low back pain.

In addition, 75% said they experienced side effects, such as constipation (65%), sleepiness (37%), cognitive issues (32%) and dependence (29%).

The use of opioids also carried social stigma with 41% saying they felt judged because they use opioids.  Interestingly, even though 68% of respondents were also being treated with antidepressants, only 19% of them felt a stigma from using those medications.

The researchers also note a “lack of solid studies on the effectiveness of opioids in treating back pain beyond 12 weeks.”

“Patients with chronic low back pain, persistent pain lasting more than three months, should see a pain medicine specialist who uses an approach that combines a variety of treatments that may be more beneficial,” said Dr. Buvanendran.

“These treatments include physical therapy, bracing, interventional procedures such as nerve blocks, nerve ablation techniques or implantable devices, other medications such as anti-inflammatories and alternative therapies such as biofeedback and massage,” he added.

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Authored by: Staff

There are 30 comments for this article
  1. Maureen at 5:05 pm

    Mr. DeMay,
    Great description of your injury, surgery, pain etc journey. It’s a crying shame what NYS has done to you. So wrong! State by state it is happening and it’s a sin! ! Keep strong and keep fighting the fight alongside us all.

  2. Andrew DeMAY at 12:37 pm

    My name is Andrew DeMAY. I had a thirty year career in healthcare management, primarily regulatory affairs, policy, and quality assurance. I worked in facilities spanning the entire spectrum of care and also had a business as a healthcare consultant. Early in my career I was the Director of Security for a hospital with a psych unit. I suffered a back injury doing a take-down on a psych patient. Surgery #1. Over the next twenty years of my career, I had four more surgeries (Two laminectomies, two fusions, spinal cord stimulator, nerve blocks, etc. etc. the whole gamut.) I would have surgery and return to work. For the last three years of my career I worked every day with a daily dose of 100mg Fentanyl and eight 10/325 mg Percoset. After a year of the fentanyl, I was switched to three 80mg Oxycontin (plus the eight 10/325mg percoset). I continued to work during this time (usually 10 hour days, plus 24/7 on – call) until my final surgery. My employer had made accomodations for me and didn’t want me to leave. The Doctors said I was done. That was 2009. I felt I no longer needed the oxycontin, and was switched to a lighter dose of 60mg morphine sulfate twice daily, plus the eight 10/325mg percoset. For almost six years this treatment gave me relative stability and acceptable mobility ambulating with a cane. No side effects, no problems, liver function test quarterly. Along comes the news of the “Washington State Guidelines” on treatment of chronic pain. It was getting too expensive for the state and insurance companies and the greedy bastards promulgated pseudo – guidelines to cut their losses. Now each state has similar “guidelines”. I live in NY State where 12NYCRR 327.2 serves this purpose. In October of 2016 NYS Comp. Court sentenced me to death by refusing further treatment with these medications, despite extensive and well – charted evidence of stability and quality of life. Do not be fooled by articles like the one above. I know the regulations inside and out. You know you’re doomed when the Judge says: “If only you had cancer we could help you”. If this organization truly wants to help folks with chronic pain, they would support the use of opiods. There is plenty of data, and there have been plenty of studies done around the globe. It’s all about the money.

  3. Jess at 1:23 pm

    I have been on the same dose of er morphine sulphate for 5 years now and the same dose of ir for 2 with no tolerance and 90% pain relief. My issues cause very severe pain and my doses are 100mg er and 30mg ir both twice a day with most days i only need 1-1.5 of the ir. These morons that say that there not useful beyond twelve weeks are just plain wrong. Without these meds i would not beable to function,with them i do yard work,car repairs,home repairs, attend family activities and am a active father to my children and a husband to my wife, without them i need to be washed and dressed by someone, i will never go back to that, i will not put my family through that again or let my kids witness that, i would eat a bullet before letting that happen. I will not let pain do that to my family, i they take my meds away its the same as if they murdered me with a gun. I am functional, active and happy as can be considering my diseased state.

  4. Kurt WG Matthies at 10:22 am

    I love these comments and how our readers can cut through the BS with their knowledge and experience.

    Remember good people that this manure is being shoveled to the public and family practitioners, and that we are in a struggle to win the hearts and minds of Americans in their understanding of chronic pain, the relative efficacy of opioids, addiction, the “epidemics”, etc.

    Feedback here is supportive and creates community, but don’t forget to inform, remind, or harangue friends, family, doctors, pharmacists, and anyone else who will listen, the importance of opioid therapy in your pain management regimen.

    In our time, every pain patient must be an advocate for effective pain management, which includes access to adequate dosing of opioid analgesics when needed.

    Spread the word.

    @kwgmatthies

  5. D.Riggs at 3:11 pm

    This cannot possibly be considered scientific evidence -this weak & loose research! How & where was it collected, how were the questions worded & allowed to be answered-can we see a sample? Were all participants under the care of a pain management specialist? Research can be used to support most anything-depending.
    Did all the participants undergo genetic testing on CYP2D6, for a genetic mutation which dictates how pain medications are metabolized-if at all?
    “CYP2D6 acts on 25% of all prescription drugs. Approximately 7% of the population has a slow acting form of this enzyme and 7% a super-fast acting form. Thirty-five percent are carriers of a non-functional CYP2D6 allele, which especially elevates the risk of adverse drug reactions when these individuals are taking multiple drugs.
    Drugs that CYP2D6 metabolizes include selective serotonin reuptake inhibitors (SSRI), tricylic antidepressants (TCA), beta-blockers, opiates, neuroleptics, antiarrhythmics and a variety of toxic plant substances. Specific notable drugs include Prozac, Zoloft, Paxil, Effexor, hydrocodone, amitriptyline, Claritin, cyclobenzaprine, Haldol, metoprolol, Rythmol, Tagamet, tamoxifen, and the over-the-counter diphenylhydramine drugs, Allegra, Dytuss, and Tusstat. CYP2D6 is also responsible for activating the prodrugs codeine and other opioids into their active forms. The analgesic activity of the drugs is therefore reduced or absent in CYP2D6 poor metabolizers.”
    I am a “Poor Metabolizer”, the vast majority of opiates do not work on me. Nor can I take the non-opiates without the threat of toxicity and/or serious side effects. I can take morphine since it does not need to be converted into an active form. I suffer with intractable & chronic pain from spinal adhesive arachnoiditis, other areas & causes of nerve root compression & stenosis due largely from a hospital born staph infection in my spine, and RSD. So what are my choices that will not harm my stomach or vital organs? I have been told a spinal stimu. cannot be used nor will it help. I cannot believe we have gotten to this point. Politics & money driving this down bound train?

  6. connie at 8:24 pm

    Alex C, you are one of the lucky ones. There are many of us who have tried everything and the only thing that works is strong pain medication!

  7. Alex C at 3:03 pm

    Instead of masking my back pain with opioids, I sought out a posture specialist. A Gokhale Method teacher taught a small group course over a weekend and I learned simple techniques to maintain a healthy posture. This addressed the root problem. No pills, no surgery…no more back pain!

  8. connie at 2:58 am

    When I was put on fentanyl many years ago I the doctor and I talked about the possibility of dependence. He asked me what would be so bad if I became dependant since my pain issues were not going to go away and would most of get worse. I was sadly very right when I answered that not having a doctor who would prescribe it was the only thing I could think of. I didn’t know just how right I was when after all these years of being on the same dosage I was forced to quit using it! I can’t even be sure that I will be allowed to continue using the extended release oxy that is nowhere near as effective with several side effects that I didn’t have with fentanyl! A person can get dependant on anything, not just opiates! How often have you heard of a “runners high” or people who can’t live without their coffee? This whole thing is wrong on so many levels but I fear that we have only scratched the surface of this witch hunt and the resulting horrors.

  9. Jean Price at 10:16 pm

    Seriously…staff authored this article?? That’s sad…but then I’m forgetting they aren’t really in the business of advocating FOR us…just seems as if they could be!! Especially since we are their main readers!! Disappointing!

  10. Tim Mason at 8:05 pm

    dependence (29%). This is really not a bad thing. If it works you are dependent on it. Is a diabetic dependent on insulin? Is my car dependent on gasoline. If you cut back there are some side effects but you can work through it. It does not mean you are addicted. I took morphine for 8 months and my body got used to it. I had to switch to Fentanyl last week. I have a lot of room to move with that medication. However, at 59, who is to worry about a little dependence. All drugs have risks. Everything from Aspirin to Zoloft.
    If you are old enough and have enough images indicating a pain causing pathology and are using the right doctor there will be no problems having your needs met.
    It is an equation. Write down the equations and determine what parts are missing. Fill the missing part. Problems solved.

  11. HAZZY at 9:03 am

    THE MEDS I TAKE STOP MY CHRONIC PAIN TOTALLY, IVE HAD THE OTHER TREATMENTS AND THEY DO NOTHING.H

  12. Lynda at 8:47 am

    I am a Chronic Intractable Pain Patient with CRPS/RSD Lupus SLE just to name 2. I have struggled with pain for 24 years. I would love to be free of pain with other methods just as soon as someone finds some that actually work not just because some doctors not in pain says they will. I have pain throughout much of my body. After years of failed trials with all other conservative modalities. Everything else failed to relieve my pain I was left with opioids for any kind of pain relief at all. For over a decade opioids have kept my pain under control and stable at the same dose. Opioid pain medication has been life saving medications for me and my family. I don’t know how I would have survived without them. Opioids when taken with the up most respect and responsibility prescribed by a trained pain management doctor can be taken long term with complete success without any negative side effects, abuse or diversion & I plus millions of other pain patients are proof of that & you so called doctors & all other know it alls need to look just past your nose & see all of us right in front of you when you claim you don’t know if long term treatment with opioids works. Why do studies it is simple look at the pain patients on long term treatment records in your own offices to see the proof of opioids working long term in chronic pain patients. It is all an excuse a cop out so doctors don’t have to stand up & fight for their pain patients they know full we are not addicts abusers or diverting. We are living proof opioids works & the increase in deaths & suicides from unrelieved pain even further proves it. But meanwhile everyone sitting on their high horses decides what people in horrific nonstop pain should or shouldn’t be allowed those of us that had been doing great are now not because of it. The bottom line of this entire opioid so called epidemic is money greed that is pushing this entire agenda. It all leads back to the money who is getting it who isn’t & who is willing to make people suffer to get it is behind this whole convoluted mess.

  13. Maureen at 6:48 am

    Doug, Ditto ditto ditto!! Well said! My story is very similar…
    12 yrs. post auto accident while working as a nurse (someone plowed into me coming through an intersection and changed my life that day) and 4 spine surgeries and many many treatments later…. I consider myself a ‘pro’ at what is wrong with my spine today, including nerve and deep tissue damage etc etc. I’m the one who FEELS IT EVERY MOMENT.
    To get a doctor to simply listen to our details of our sufferings is like pulling teeth. Needless to say…aside from living in pain, that in itself is emotionally haunting and draining.

  14. Cynthia at 11:59 pm

    Another ridiculous article. Just another so-called professional making faulty arguments. The side effects and potential permanent damage caused by the other meds used for pain , besides opioids , are well known but they don’t care. This whole crusade is evil…it’s causing profound and widespread suffering and needs to be stopped. I would like to know what’s really driving it. Surely it’s not concern for the people dying from heroin. They don’t care about them, nor do they care about veterans Committing suicide because they can’t get pain relief. There’s a monetary motive somewhere. Maybe pharma has new non narcotic pain meds they want to force on us, like Guinea pigs, without years of testing. Opioids have been around a long time. I trust the one I take. I don’t want to do ablations or nerve blocks or any other barbaric and painful procedures. Leave us alone. We are getting through life as best we can. And to all these “experts”, hear this: YOU try living in constant pain for a week, then tell us how you feel about it.

  15. Doug at 11:51 pm

    First, I seriously can’t believe that this publication would be promoting this load of BS.

    Second, I’ve been through every single alternative treatments refered to in this article and now I’m totally disabled because of injections and implants.

    Third, physical therapy does wonders if an injury is new and treatable, but deep tissue and bone damage can get worse if miss diagnosed and improperly treated.

    Forth, this article spacifically talks about lower back pain. Lower back injuries usually occur from improper lifting so it’s usually muscle strains that cause the pain. Yes, in this instance other treatments should be used before moving on to opioid medications. Physical therapy and muscle relaxers work well in these instances and if the injury is properly diagnosed in the first place, it can be treated accordingly.

    Finally. Most lower back injuries happen in the work place. After the initial injury workman’s comp and the employer will first order a UA drug test. Next they will order x-rays to make sure no bones are broken. Then the treating doctors will do a range of motion test to see how far you can bend over or turn side to side.
    Then they will diagnose you with either a muscle strain or bruise. Next they prescribe you 30 muscle relaxers, 30 600 mg Ibuprofen and physical therapy 2 to 3 times a week.
    These doctors who are involved with workman’s comp claims have no idea if there could have been tissue damage because x-rays won’t show that. This is exactly how my current situation started only my back injuries happened quite often because I was not given an MRI to determine the extent of the damage from my initial injury. As a matter of fact after my 4th back injury at the same company, they decided that I was a liability and created a BS reason to terminate me.
    Here’s the kicker, if they would have determined the extent of the tissue damage and treated me for that to begin with, I honestly believe that I would still be working full time and without or in very little pain today and I’m sure that there are thousands, if not hundreds of thousands of people out there with similar stories to mine.

  16. Barbie at 9:19 pm

    I have gone through therapy, biofeedback, hypnosis, done and still try to do yoga as much as my body allows, exercise, I ride my bike, I even moved to another state.I use a TENS, a cold pack and heating pad daily. I have had cortisone shots, epidural shots, nerve blocks, nerve ablation techniques, etc. As of my last pain mgmt appt, I asked my Dr. If there is anything he could do to help me. His response “no, but we will work on getting you off your pain meds”. I had have a total hip replacement which also included 5 other hip surgeries, back fusion, neck fusion of c3,4,5,6,7. Knee, foot,elbow surgery. Nerve damage from neck and hip surgeries. I can no longer take anti-inflammatory as they have burned a hole in my esophagus and now have a hiatial hernia.
    Pain meds have been my only relief, but I am only 52 and since my last MRI my degenerative disc disease has now moved into my T region. My Dr continues to ask me the same questions each session and I respond the same way, he continues to decrease my meds and I feel I will be at my wits end eventually. Bike riding is challenging when you cannot turn your.neck to see if there is a car coming up behind you.I moved from a state that was so high in crime, to a state where I feel house bound. The DEA is making decisions about opioid production, the government is choosing how to run my life. I wish congress and the Senate could spend just one week in our pain riddled bodies and maybe different decisions would be made.
    I am willing to have a shorter quality of life than a longer agonizing one of daily pain and crippling joints. The people that are abusing the drugs are not the people that need the drugs. The people abusing are the people after the high. I can honestly say, the people in pain don’t get the high, we get relief. We are not the abusers, we are not the doctor shoppers, we are the ones in pain. I am the person who locks up my drugs so they do not fall into the wrong hands. Unfortunately, for people like me that are truly in pain, I will not trade my pills, or bargain them for goods because they are precious and we never know when the government will take away our basic human right to live with dignity, I am the one being penalized for doing the right thing. My access to a prescribed health care after all avenues have been exhausted is being taken away because of other people abusing the system. How is this fair practice?

  17. Laura Robertson at 8:17 pm

    I am so offended by articles and attitudes such as the one voiced in this “article”.

    I have been on opioids for over two decades. I was on the wrong one and was not pain managed on an outrageous life-threatening daily dosage.

    I was taken off and placed on other non-narcotic medications which had me so stoned I couldn’t function.

    I now have a reasonable pain management setup. Finally. After twenty years. Between weekly nerve block injecations, and significantly lower doses of opioids, I am slowly regaining a quality of life that ten years ago seemed impossible.

    “They worry about the stigma associated with taking them.” Of course we do. Every time we turn around we get told to get off the narcotics, and are treated like drug-seeking addicts, you bet we worry. Wouldn’t you?

    The article also notes a “lack of solid studies on the effectiveness of opioids in treating back pain beyond 12 weeks.” Show me longitudinal studies which have statistics of more than twelve weeks. TALK TO YOUR PATIENTS!

    Research our options, and stop stigmatizing us for finding relief (albeit far from perfect) from the present regimen of opioids available to us .

    Tolerance and dependence are NOT addiction. Give me a realistic alternative that has not been pushed through trials, and call me non-compliant when it doesn’t work, and winds up killing 7% of us due to “unforseen” consequences.

    Listen to the wealth of information that Persons With Pain (PWP), have. We know what we are talking about. You only need to listen, without judgement.

    Is that too much to ask?

    Apparently it is…

    Laura
    chronicpain@bell.net

  18. Kathy C at 7:45 pm

    “The researchers also note a “lack of solid studies on the effectiveness of opioids in treating back pain beyond 12 weeks.””

    One more of these deliberately obfuscating “Articles.” Well at least they all agree on one thing, “there is not enough research.” This assertion is repeated in countless “Studies” “News Articles” and other mentions of Chronic Pain and the effectiveness of Opiods. We can only speculate on the reason they never collected this information. There would be an easy way to get this information, after all there are thousands of people who have used opiates for Decades. This information would be available at any Pain Practitioner, or they could backtrack Insurance records as they do for most other issues. Of course the Criminalization of Pain Patients and Physicians might make them not want to participate.
    This information was never collected because it was never necessary to justify the use of these medications, since they have been used for Millennia. The other incidental information would be the number of Health issues that modern medicine cannot alleviate, let alone cure. The number of people who have successfully taken Opiates for Decades, also contain a high number of Medical Mistakes, the failed back Surgeries, useless Hip Surgeries, and other assorted conditions that medicine made worse. See if you don’t like the implication of the data, you just don’t collect it. They can then look to the absence of data as a reason for more mindless speculation. They do it all of the time. Of course if the Data showed a profitable conclusion, it would be be all over the Media. The conclusion form that data does not fit a Narrative they are promoting. Yet a meaningless six month study of tortured rats, gets front page billing, and mentioned on the nightly news.

  19. CathyM at 4:42 pm

    Another vague post about some vague alternatives – as if insurance would cover “multi-modal”… and I just barely escaped (I think) w/o permanent harm from taking ibuprofen for years – I complained of bowel issues all summer and only when I tested with significant anemia (and also had to stop iburprofen pre-surgery) was it evident that I’d had all this incredible pain & suffering from a “safe” OTC med!! Never again! Opioids have fewer side effects and I haven’t had any while taking them!

  20. Gayle Hays at 9:43 am

    So, 75% said the opioids were somewhat or moderately successful. Sounds like pain relief to me. And it is certainly better than nothing. So why should people be forced to stop a treatment that is working for them, if they are happy with the results, because of the stigma? Why not address the stigma instead?

  21. Judy Jaeger at 9:35 am

    WOW……what a load of BS!!!!
    “They were asked about how successful the opioids were in relieving their pain and only 13% said “very successful.” Many (44%) said opioids were “somewhat successful” and 31% said “moderately successful.” The remaining 12% said opioids were “not successful” in managing their low back pain.”
    ……..so if you add up those numbers, 88% said opioids were moderately to very successful….how does that translate to they don’t work????? smdh.

  22. cliff macway at 8:26 am

    I don’t care what people think any more. Articles like this do not address chronic pain patients in a true light at all!

  23. Donna Rubinetti at 7:18 am

    Has anyone had nerve ablation? I have RSD that has moved from shoulder to nerves in spine and feet. I’m afraid of SCS, intrathCal pumps, etc, but am increasingly disabled. ANY feedback would be helpful.

  24. Maureen at 6:57 am

    Really?! Good informational post but… truly…this does not apply to ‘most’ who visit this site who have been through years and years (shall I go on?!) of interventional treatments and surgeries and have made it clear over and over that opioids are the best treatment of all for us.
    We’d surely NOT have to take them but we have come to know what works best for our chronic pain. Agree???

  25. Maureen at 6:47 am

    Why are so many patients taking both an ant-depressant and an opioid? That is something that appears to be brushed over and dismissed in this article. A very fatal combination. And if physicians are not aware, and not using their state PDMP, this legal grit poisoning epidemic will rage on.

  26. Carl Dobs at 6:37 am

    Hogwash! Real chronic pain is pain that lasts more than 2 to 30 years, not more than 3 months, Real chronic pain patients have already tried the alternatives that Dr. Buvanendran lists.

    As far as interventional treatments (Mostly epidural steroid injections, what about the recent 2012 NECC (New England Compounding Company) disaster. 14,000+ got ESIs for mostly chronic back pain. The “medicine” was contaminated with a variety of species of fungi that caused over 800 infections and 78 deaths. These are the “official” numbers from the FBI and CDC but there are more victims who are not tabulated. (A physician in California published data, yet CDC lists NO cases in California because the California Dept of Health did not report any.) The FBI has lodge murder charges against the owner and chief pharmacist. Many of the surviving victims have ongoing residual neurologic and psychologic damage. In fact for the people who were inoculated with NECC fungus, the death rate is 100 times the death rate of opioid poisoning!

    Add to that the data from FDA on subsequent inspections of the “Outsourcing Facilitiies”. Those are the large scale compounding companies that supply injectable medication to many of the interventional clinics. With a few notable exceptions, almost ALL of the facilities have been cited by FDA inspectors as having UNSTERILE conditions. (Over 50 of the 60 facilities inspected have been cited.) And yet virtually all of them continue to produce supposedly sterile medication, and to sell it as sterile for injections into human patients!

    So any one considering these nerve blocks should insist on knowing the source of the medication to be used. Anyone considering getting such a block should make sure that the medications are coming from a manufacturer or “Outsourcing Facility” or Compounding Pharmacy that has passed FDA inspection for adequate procedures to assure sterility. There is a very high probability that clinics and doctors offices continue to use steroids and other injectable meds from producers that have not passed their most recent FDA inspection. (It is indeed mindboggling that the FDA continues to allow these companies to distribute their goods.)

    There is in fact a lot of data available about the beneficial use of opioids in true chronic pain (lasting 2 to 30 years). It is just that the academic community has simply failed to collect the data. There are well over 10,000 people with Chronic Intractable Disabling Opioid Responsive Pain. The true data about their condition and their positive response to opioids, and for some the NEGATIVE response to interventions, and their minimal to moserate response to other treatments still awaits collection, analysis and dispersion. What is lacking is an academic cadre of doctors willing to look openly and honestly at the hidden data. I know for a fact that the people who suffer pain are willing to share their stories.

  27. connie at 6:26 am

    It’s amazing that people without chronic pain KNOW that opiates don’t help! Wish karma would hit them hard and permanently!

  28. Gotnerve at 5:59 am

    Meant to say insurance fails to cover most non medicinal therapies…

  29. Gotnerve at 5:58 am

    Problem is insurance fails to cover almost all. In medicinal therapies like massage, PT deductible, some bracing, biofeedback …

  30. HJ at 5:10 am

    Moderate relief is still relief.

    I had a doctor talk with me about expectations… that I shouldn’t expect to be “cured.”

    Well, now I see studies that seem to imply that if you’re not cured, then they’re ready to toss the treatment out.

    Yes, there are alternative treatments… some of which are not covered by insurance, some of which are covered but are so costly that they’re prohibitive (my $60 per-visit copay on physical therapy that they want me to go to three times a week), for instance… and other treatments are invasive.

    By all means, make the patients aware… give them options. At some point, I might be open to trying an invasive procedure. But also, be realistic with patients about their expectations too. I’d be pretty resentful if I went through an invasive procedure, expecting it to end my pain, and learned otherwise after-the-fact.

    The study is saying that drugs provide moderate relief, without any comment on what kind of relief these other modalities provide. If they provide moderate relief, then perhaps they should be tossed aside like opiods, right? I mean, it’s not like there aren’t potential side effects to invasive treatments, right?

    This is just a misguided attempt to feed into the anti-opiod propaganda. I’m absolutely supportive of alternative treatments but I’m resentful of how they’re presented and how this reinforces the “stigma” that the study talks about.

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