Ep 8. Why Not Everything Works for Everybody
The hard truth is it's normal for treatments, especially medications, not to work. But how many patients do you actually have to treat to improve things for just one even? This is where the concept 'number needed to treat' is critical to better understand so that expectations don't lead to resentments.
Managing expectations as a patient is hard, it's even harder when they're unrealistic. Unfortunately, there is little conversation around what is likely to work in various settings, and what their likelihood is to compared to other options. We'll go through how you should trial medications, ways to improve communications with your provider, touch on the ecological fallacy, explain how experienced clinicians can overcome some of this, and define what evidence-based medicine actually is and should look like.
Introduction
In this episode of "It's Not in Your Head," Dr. Dan Bates and Justine Feitelson delve into the concept of "Number Needed to Treat" (NNT) and why treatments often don't work as expected for chronic pain patients. This discussion aims to set realistic expectations for both patients and practitioners.
Key Concepts
Number Needed to Treat (NNT)
NNT is the number of people that need to be treated to get one person better compared to a placebo. For example:
Amitriptyline: NNT of 4
Duloxetine: NNT of 6
Gabapentin/Pregabalin: NNT of 8
Effectiveness of Treatments
Most treatments have a 30-50% chance of providing a 30% decrease in pain
Placebo effects account for a significant portion of pain relief
There is no "magic bullet" for treating chronic pain
Context Matters
NNT can vary depending on the condition being treated. For example:
Duloxetine for neuropathic pain: NNT of 6
Duloxetine for back pain: NNT of 10
Treatment Effectiveness for Back Pain
Exercise: NNT of 7 (50% chance of 30% pain decrease)
Oral anti-inflammatories: NNT of 6
Capsaicin: NNT of 6 (64% chance of 30% pain decrease)
Opioids: NNT of 16 (39% chance of 30% pain decrease)
The Ecological Fallacy
Dr. Bates explains the concept of ecological fallacy, where group data is incorrectly applied to individuals. This highlights the limitations of current evidence-based medicine practices and emphasizes the need for personalized treatment approaches.
The Role of Experience
Experienced clinicians can often predict treatment outcomes better than relying solely on group data. This is due to their accumulated knowledge from treating thousands of patients and reading numerous studies.
Implications for Patients and Practitioners
It's normal for treatments not to work or provide limited relief
Don't stay on ineffective treatments indefinitely
Maintain open communication with your physician
Reevaluate treatments and dosages periodically
Combine multiple interventions for better overall pain management
Evidence-Based Medicine
The true definition of evidence-based medicine involves:
Best available science
Experience of the clinician
Desires of the patient
Final Thoughts
There are no magic bullets in pain management
Be wary of treatments promising miraculous results
Focus on addressing specific features of pain (e.g., inflammatory, myofascial, central sensitization)
Having appropriate expectations can reduce frustration during the treatment process