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• Citation: Schneiderhan J, Clauw D, Schwenk TL. Primary Care of Patients With Chronic Pain. JAMA 2017 May 18. doi: 10.1001/jama.2017.5787. [Epub ahead of print] 

• Critiques:

1. Appeal to status and ethics fallacy: Under the banner of "primary care" and "responsibility", the authors claim to be providing a review of a "comprehensive approach based on an understanding of chronic pain pathophysiology that emphasizes the patient-physician relationship, shared decision-making, nonpharmacological treatments, and selective use of nonopioid pharmacotherapy.​"

2. Overt message: The main message of this 2-page conversational review is that physicians should avoid over-prescribing opioids in favor of the treatments outlined, which are drugs of various classes plus nonpharmacologic treatments.

3. Drugs, drugs, and more drugs, with a weak recommendation for weak treatments to give the illusion of open-mindedness and eclecticism: The drugs overtly endorsed and encouraged in this review are as such: "Several drug classes should be used before opioids, including tricyclic antidepressants, selective serotonin-norepinephrine reuptake inhibitors, and gabapentinoids." Notice that stating "Several drug classes should be used before opioids" is still an overt endorsement for the use of opioids. 

4. Pay-to-Play: All of the drug classes endorsed are drugs produced by the financial sponsors of the second author Clauw. Drugs endorsed include: "opioids, tricyclic antidepressants, selective serotonin-norepinephrine reuptake inhibitors, and gabapentinoids." Clauw's sponsors are Abbott Pharmaceutical, Aptinyx, Astellas Pharmaceutical, Cerephex, Daiichi Sankyo, Pfizer, Laboratoires Pierre Fabre, Samumed, Theravance, Tonix, and Zynerba.

5. Endorsement of stupidity and ignorance: I am always amazed at the medical profession's selective ignorance and intentional stupidity on major topics such as nutrition and other nonpharmacologic interventions, generally via employment of the "lack of sufficient science fallacy." Apparently, the medical profession would have us believe that major scientific advances are within reach such as mapping the entire human genome and discovering the molecular basis of most diseases, but understanding nutrition is too complicated.  In this case, the authors state "Cannabinoids may also have a role, although behavioral adverse effects, legal uncertainties, and inadequate data about dosing limit their use." The absurdity of this statement can be deconstructed: 

   1. behavioral adverse effects: These are minimal in their totality, but especially minuscule when compared with the dangers of NSAIDs and opioids which are distributed like candy on a daily basis. 

   2. legal uncertainties: In this case the authors are referencing the utterly stupid criminalization of a botanical medicine (Cannabis sativa/indica) with a proven safety and efficacy record that is the envy of any prescription drug on the market. 

   3. inadequate data about dosing​: This is a completely idiotic statement; all drugs are "dosed to effect" and Cannabis is no exception. 

6. Generally worthless nonpharm(acologic) treatments that most primary care doctors wouldn't waste time with: The usefulness of impotent nonpharmacologic recommendations is that physicians feel falsely empowered by these pseudoreviews that give the impression that all options have been considered; after their expected failure, physicians are then empowered to use invasive treatments and to resort to the very treatments (ie, opioids) that were negated at the start of the discussion. 

   1. "structured educational programs": No primary care physician (PCP) can take action on this recommendation as it is written and described; however, they can write a prescription for the showcased drugs that are endorsed by this article. 

   2. "psychological therapies, with cognitive behavioral therapy: Most PCPs are not going to waste time with this, or they might recommend a psychotherapist at best. 

   3. "mindfulness meditation": Another near-waste-of-time that does nothing to address the underlying pathophysiology of neuroinflammation that underlies chronic pain. 

   4. "increased activity through structured exercise programs (usually walking)": Same as #3 immediately above: another near-waste-of-time that does nothing to address the underlying pathophysiology of neuroinflammation that underlies chronic pain. 

   5. "Acupuncture": Reasonable, and if properly performed (eg, to stimulate the vagus nerve) might actually reduce neuroinflammation. Acupuncture is not going to solve the mitochondrial and microbial components of chronic pain. 

   6. "alternative movement therapies, such as yoga and tai chi​": Another give-me-a-break recommendation that either/both PCPs will not recommend and/or that does zero to address the underlying pathophysiology. 

7. The metamessage contradicts the stated message: ​The final result of the main messages of this article 1) don't overuse opioids, 2) use the paid endorsement drug list, 3) recommend generally ineffective nonpharmacologic treatments actually results in more use of 1) opioids, and 2) the expected failure of the recommended drugs and the nonpharm treatments. In essence, nothing changes; patients are left un(der)treated and drug-dependent, maintaining their status as "patients for life" which is exactly what the pharmaceutical industry and "medical establishment" want to see happen.

Have you ever wondered why (pain) medicine consistently fails to make clinical progress despite lauding itself (perhaps appropriately) for its cellular/physiologic progress and insights? Articles such as the one above which promote vicious cycles of nonprogress are part of the reason; now imagine this occurring thousands of times for thousands of students and doctors in millions of conversations. Medicine is in a rut because medicine wants to stay in a rut of patient dependence and noncurative treatments. 

 

Where can doctors learn about the clinical management of acute and chronic pain via evidence-based nutritional and functional interventions?  

• Large textbook: Inflammation Mastery

• Clinical protocol book: Volume 2: Clinical Protocols 

• Color-printed book and ebook: Pain Revolution

• Grayscale book and (color) ebook: Brain Inflammation

• Small ebook excerpt on migraine: Migraine and Headache Revolution

• Small ebook excerpt on fibromyalgia: Fibromyalgia Solution

What is Dr Vasquez's authority on this information?

• Doctor-approved: Dr Vasquez has published/presented this information to doctors in post-graduate education conferences and peer-reviewed publications. 

• International authority and experience: Dr Vasquez has lectured to doctors and medical students nationally and internationally for 20 years; DrV has more than 120 professional publications.

• 20 years of clinical practice in various settings: Teaching clinics, private practice, outpatient community clinics (family medicine), hospital-based urgent care and inpatient medicine

• Context: Dr Vasquez has published more than 120 books, articles, and essays, most of which are directly related to metabolism, nutrition, and clinical medicine.