Jared Powell:
Today's guest is Caitlin Jones. Caitlin is a postdoctoral research associate at the University of Sydney. Caitlin's research evaluates the benefits and harms of treatments for musculoskeletal conditions with a particular interest in high risk treatment options such as opioid medicines and spinal cord stimulators for pain. I brought Caitlin on the podcast to talk about a recent randomized placebo controlled trial. Caitlin and her colleagues have published in the Lancet Journal, synchronized as the Opal Trial.
Jared Powell:
The Opal Trial investigates the efficacy of an opioid or treating acute neck and low back pain, and the results have generated some passionate debate online. Caitlin talks us through the trial, it's possible clinical implications, and fastidiously addresses some common critiques of the trial before we start the podcast. Without any further delay, I bring to you my conversation with Caitlin Jones. Caitlin Jones, welcome to the show.
Caitlin Jones:
Thanks for having me, Jared.
Jared Powell:
Caitlin, thank you very much for coming on. I'm really keen to chat with you about some of your recent controversial, interesting research. However, before we get into that, can you please introduce yourself to the audience?
Caitlin Jones:
Sure. So my name's Caitlin. I'm a postdoctoral research fellow at the Institute for Musculoskeletal Health, which is at the University of Sydney. Before I was a researcher, I was an occupational therapist, and yeah, I became very curious about the evidence behind how we treat people with back pain. And so I took a bit of a side step from my clinical job as an OT into doing a PhD. And I loved research so much that I'm still here doing it now.
Jared Powell:
You're one of those weird ones that love research. I love it. So as an ot, and I was just telling you this off air physios, just think of OTs as like upper limb dominant. Mm-Hmm. the back is not in the upper limb. How did you get interested in in back pain research?
Caitlin Jones:
Yeah, so that's, I think a common misconception about OTs is that there's a certain body parts that we focus on, but the job I had before I started my PhD was in rehabilitation. So sort of looking at someone's whole body, whole life, whole situation and helping them get back to the occupations, the activities that they, you know, want to and need to do. And so a lot of the patients I worked with had chronic back pain and they'd had all sorts of treatments, often including surgery, and we are just looking to get back to their normal life as best as possible. So there was usually an OT in their treating team along with physios and other allied health professions as well, and medical professionals. And yeah, we all work together to, to try to help these people get back to their normal lives.
Jared Powell:
Yeah, awesome. Physios are so ignorant of occupational therapists and what they do and the value that they provide in a health setting. So I'm gonna be fully on record and, and say that and apologize because when you actually look at what OTs do in terms of getting people back to meaningful activity and, and work and what have you, it's like what most healthcare professionals should be focusing on, you know?
Caitlin Jones:
Yeah. I I agree. But it's pretty broad in your defense because it is so broad. It's very hard to explain and understand. Yeah. So yeah, forgiven
Jared Powell:
. Oh, I'm gonna apologize. Yeah, thank you very much. And I apologize on behalf of all the physios listening, that's that's your professional role. What do you, what do you like to do for fun? What do you like to do for physical activity, whatever?
Caitlin Jones:
I, at the moment am fully ingrained in the culture of CrossFit. I'm really enjoying that. I moved to a new town a couple of years ago, and that was my strategy to make some friends. It was to join a CrossFit gym, and it was so successful. I made excellent friends there and fell in love with the sport. So that's what I do for health and fitness. And when I'm not working or at CrossFit, I am helping my husband build our house. So we've been working on this for the last couple of years. Feels fraudulent to say we, he's doing 99% of it, and I am helping with things like painting and sweeping up and, and whatnot. So yeah, that's kept me pretty busy outside of work.
Jared Powell:
Cool. Yeah, I've sort of done similar actually, and it's learning all these new tasks, like around the house has been really fascinating. And, and YouTube, you can pretty much learn everything. I've really enjoyed that. It's amazing. Have you enjoyed it?
Caitlin Jones:
Yes. Yeah. It's been very handy. Yeah.
Jared Powell:
Yeah. Yeah. Good. 'cause honestly, before, before you have a house, it's I couldn't hammer anything into the wall. And now a few years later, Caitlin expert, you think
Caitlin Jones:
You're a pro . Yeah,
Jared Powell:
. It's yeah, no, it's, it's been good fun. And so tell me about CrossFit in terms of your experience with that. What do you like about CrossFit? Is it the intensity of the workout? Is it the v the varied nature of it? What's what's the addictive thing for you?
Caitlin Jones:
It's primarily the community. The fact, you know, you go and you're with friends every time you work out. The other bit that I really enjoy is learning new skills. Like, I, I'd sort of worked out in the gym doing some basic weightlifting or, or running and, but I'd never learn, you know, the skill of different Olympic lifts and whatnot. So just to kind of be distracted from the suffering by thinking about this new skill of how to move my body, I just found it, it just was kind of addictive. And yeah. Now if there's a, you know, the days I don't go, I just, I'm, I miss it. I miss the people, I miss the, the feeling. Yeah.
Jared Powell:
Yeah. That's awesome. Good on you. Okay, so let's chat about this really cool randomized control trial that you've just published in The Lancet. And I will read out the formal title, which is called Opioid Analgesia for Acute Low Back Pain and Neck Pain. And the acronym is a really catchy acronym, which is the Opal Trial, as I mentioned, published in the Lancet basically this time last year. So Caitlin, I want you to give us a brief little entree introduction into this trial. What were the sort of background and forces that led to the development and execution of this trial? And basically, why did it need to be done and what was the primary research question?
Caitlin Jones:
Sure. So opioids are the most commonly prescribed medicines for people that have acute low back and neck pain. So, for example, people that go to the GP with acute back and neck pain, about 40% of them will be given an opioid. And people that go to the emergency department, it's more like 70% of them will be given an opioid. So they're two really common conditions, like back pain is responsible for the most disability in the world, and that this treatment, opioids are really highly used. And it's, they've been somewhat recommended by guidelines. You know, guidelines are, are sensible and there's some caveats in there, but many do say that you can consider an opioid where other treatments have failed or been contraindicated. But before Opal, there was no direct evidence actually supporting that. So those guideline recommendations weren't based on any direct evidence.
Caitlin Jones:
We know that opioids are a high risk treatment. You know, most people have heard of the opioid crisis, which is this global crisis that's been caused and fueled by over-prescribing opioids. So we already know that there's a lot of risks attached to using them, and that it's really important that we're only using them to treat conditions where we know the benefits are big enough that they outweigh the well-known risks. So given how common back and neck pain were and how common opioid use was and how high the risks potentially are, was just obvious that there was an urgent need to fill that gap and do the world's first trial comparing an opioid to a placebo for this population.
Jared Powell:
Yeah, it sounds, it sounds like an obvious question when you put it like that, Caitlin. So when we're talking about back pain and neck pain, are we just talking about all types of like mechanical back pain once we've ruled out red flaggy type presentations? Yes. What's the, what was the inclusion exclusion criteria?
Caitlin Jones:
We are talking about non-specific low back and neck pain. And that basically means it's your garden variety back and neck pain where there's no obvious cause. Which is the vast majority of back pain. We've ruled out things like malignancies, infections, fractures that require specific treatments, and we're just left with this really common diagnosis of non-specific back pain and neck pain.
Jared Powell:
Are we including sciatica, quote unquote sciatica or radiculopathies or, or not.
Caitlin Jones:
People in the Opal trial could have had referred arm or leg pain. They didn't need to have it, but they weren't excluded if they did have that alongside their back and neck pain. Cool.
Jared Powell:
And yeah, so this opioid crisis is everywhere, right? Mm-Hmm. It's, it's in the media. There's a Netflix show on it, which means it's entered, entered the, the cultural zeitgeist. Mm-Hmm. I haven't watched it yet. Have you watched it?
Caitlin Jones:
Yes, I have. I've watched, yeah, there was a show and a documentary in both. Pretty fascinating, accurate as far as I know. Yeah, it's a pretty incredible story of how marketing and medicine got intertwined and caused a heck of a lot of damage.
Jared Powell:
Yeah, this is set up beautifully and people should go and watch the show and I'll watch it when the, when the Olympics is finished. Okay. So, so what were the results of the trial? So what, what exactly did you do? What were the methods? So
Caitlin Jones:
In Opal we recruited 347 people who were seeking care, so who were going to their GP or an emergency department asking for help with their acute back or neck pain. By acute pain, we, it needed to have been going for less than 12 weeks. And then those people were randomized to a short course of either an opioid or an identical placebo, and nobody knew which was which, and they were to take them until they didn't need them anymore, or six weeks, whichever was longer. So no one was able to take them for longer than six weeks. That was the maximum. We measured their pain daily for the first 12 weeks, and then we also measured pain and other outcomes at intervals over one year. We found no difference in the short term for people's pain function, quality of life, et cetera, no difference between the opioid and the placebo group. However, in the long term, we found that the opioid group actually had worse outcomes, including pain function, the mental health subscale of quality of life and risk of opioid misuse in the long term as well. So what that tells us, that in the short term, the opioid did nothing to help the people that took them. And in the long term, it actually not only didn't help but seemed to worsen their recovery and led to this sort of cascade of worse outcomes over time
Jared Powell:
And long term, is that one year? Yes. Okay. And short term is weeks, months.
Caitlin Jones:
Our primary outcome was six weeks. But we measured pain yeah. Every day for the first 12 weeks.
Jared Powell:
And no statistical or clinical difference at those points in the short term,
Caitlin Jones:
At the primary time point, there was no statistical difference, but even then, we actually couldn't rule out that there was a small difference that favored the placebo group at week six. But it didn't become statistically significant until further down the track. And there was no outcome, no time point well across the entire study, no outcome and no time where there was an effect that favored placebo. There was consistently no effects or small effects that favored placebo.
Jared Powell:
You couldn't even mind for one little measly thing that, that an opioid was better. Caitlin, even if
Caitlin Jones:
We were looking for it, it wasn't there.
Jared Powell:
Someone will do it in a, in a secondary analysis . Okay. So what was the opioid that you used? It
Caitlin Jones:
Was a combination of oxycodone and naloxone. It's called Targin here in Australia, Targin.
Jared Powell:
Okay. And what's the naloxone do? What's that function? So
Caitlin Jones:
A lot of people have probably heard of Naloxone as being the antagonist to an opioid. It's sort of the rescue drug, you know, that they're using, particularly in the states, if someone's overdosing on opioids, you can administer, you know, intranasal IV naloxone, and it reverses that and can save people's lives. However, when it's taken orally, it doesn't act systemically, so it doesn't get to the brain, it just acts on the bowel. So it comes along and knocks some of those opioids off the receptors in the bowel to reduce opioid induced constipation. And if anyone listening has taken opioids, they're probably very familiar with how nasty that opioid induced constipation can be. So that's why it was important that we chose a drug that had the oral naloxone in combination to yeah, re reduce that constipation, both because it's so uncomfortable. And when a lot of these people had back pain to begin with, that's sort of the last thing they wanna be dealing with. But also because it's so obvious that if people just took the opioid without the naloxone, it would have essentially become an unblinded study because it would be so obvious to the people whether they were on the, the opioid or the placebo.
Jared Powell:
Yeah. So it doesn't, doesn't diminish the theoretical pain relieving effect of the opioid, but perhaps spares people some gut and stomach pain. Yes,
Caitlin Jones:
Exactly.
Jared Powell:
Okay. So they're the, the crude results. What are the clinical implications of this trial in, in your opinion? What, what does this mean in the whole sort of body of evidence when it comes to acute care management of, of low back pain and, and neck pain?
Caitlin Jones:
So this is the first time that any opioid has been tested against a placebo for acute back and neck pain. And this finding was clear and consistent that this opioid offered no benefits. So this, I hope, will make patients and prescribers just think twice before they use an opioid, even as a second, third, fourth line treatment for people who match the opal population. Well, and I hope it also raises some awareness about the other gaps that are out there, some things that maybe most of us thought were already tried and tested and evidence-based that actually aren't, and that there's actually a heck of a lot more trials that need to be done for our Yeah. Medical practice to be truly evidence-based.
Jared Powell:
Can you speculate as to why you think the placebo group came out statistically better after a year in the long term? Yeah,
Caitlin Jones:
I can speculate because we don't know for sure, but there's sort of two main theories that sound the most plausible to us. One is that this phenomenon known as opioid induced hyperalgesia, which we've known about for a long time, but thought that it's just, it's where you become more sensitive to pain. And so you sort of, you feel pain worse if you've been on opioids for a really long time, but maybe the OPA trial is showing us that even short term uses of an opioid can have that hyperalgesic effect in the long term. Another possibility is, although across the groups people reported an equal number of adverse events, there are a lot more of the classic opioid related ones in the opioid group, like nausea and vomiting and being really tired, the sorts of things that would make you wanna lie in bed all day compared to the placebo group that were hoarding things like a, a skin rash or a runny nose, you know, random, mild things. And so perhaps the side effects of the opioids made people less able to get up and do the, the things that we know can help recovery from back pain, like, you know, gentle activity and staying at work, and that maybe they were unable to do those things and it just sort of put them behind the eight ball compared to the placebo group and it slowed down their recovery in a way that they hadn't caught up even after a year's time. Yeah.
Jared Powell:
Yeah. That, that makes sense. Caitlin, I wanna ask you, so there's been, there has been a little bit of kickback in a social media storm. Mm-Hmm, after the publication of your findings, which is, which is good. It's what you want you, you do want criticism. That's the whole point of, of peer review. And then you put your work out into the world and, and the world can have a look at your findings and Yep. And have an opinion and, and say something which I think is really valuable and, and inherent to scientific progress. So do you mind if I bring up some criticisms that have been leveled at, at your work?
Caitlin Jones:
Absolutely. Go for it.
Jared Powell:
Beautiful. Okay. So some have challenged your use of the plural form of opioids Mm-Hmm. rather than a singular opioid. In your abstract and discussion, and also the choice of the opioid, which is oxycodone and, and naloxone commonly called targin here in Australia. What would you say in response to these criticisms? Yeah,
Caitlin Jones:
So in the paper we are really clear which opioid we used and our justification for using it. So when we discuss our specific results, we do talk about this being a trial of one opioid versus placebo in papers. It's normal to put your findings into context, you know, compare them to what else is known in the wider field. So when we make statements in the abstract and the discussion where we use opioids in the plural, we're talking about the fact that there is no evidence to support the use of opioid for the treatment of acute non-specific low back and neck pain. Because before opal there was nothing, there was no evidence guiding practice. And now that we have opal, there is one big trial that shows no effect. So it's true that there is no evidence supporting the use of opioids for these, this population.
Caitlin Jones:
And therefore our position is they shouldn't be recommended opioids as a plural shouldn't be recommended, which is different, you know, not recommending them because there's no supportive evidence is different from prohibiting clinicians from using their clinical reasoning to make judgements, especially when they've got a patient in front of them where there is no evidence that matches really nicely to them that they can use to inform their practice. So yeah, where we've used opioids as a plural, where we're talking about the wider field and yeah, we've been very, very clear the drug we tested in the study. Yeah,
Jared Powell:
That makes sense. So there is, I want to reiterate and sort of repeat your point if you, if you don't mind from what you're saying is there's no evidence at all in support of the use of opioids in the management of acute low back pain and neck pain. Is that right? That's
Caitlin Jones:
Correct.
Jared Powell:
And then your trial would, would actually argue that a placebo medication in fact may be more beneficial perhaps in the short term, but even in the long term?
Caitlin Jones:
Yeah. Not, not that I'd necessarily advocate prescribing placebos, but yeah, the, so the, the one study we have that was, you know, gold standard trial methods publicly funded fully transparent, found this really clear effect of not only not helping, but likely making worse. And, you know, we tested oxycodone, which is a, a morphine-like drug. So we do know that those results are transferable to other morphine-like drugs, but even other opioids that aren't from the morphine class. The systematic reviews that, you know, for example, on chronic low back pain that have compared all different opioids seem to have the same efficacy regardless of the type of opioid as long as the dose is equivalent. So there isn't actually much weight to the argument that, you know, we found this for oxycodone, but that a different opioid might have an effect in the complete opposite direction. That's not a likely outcome, although I wouldn't discourage people from doing the trials because we can always strengthen the body of evidence by replicating opal with slightly different populations and slightly different drugs. Yeah. The argument that you know, what we found for oxycodone might be the opposite in a different opioid just doesn't hold a lot of weight for me.
Jared Powell:
Yeah. It's not, not plausible really. Okay. So there have been questions about your findings and generalizing them to individuals with this hyperacute low back pain and neck pain Mm-Hmm individuals who we may see in emergency departments that could in principle be candidates for a fast release opioid as opposed to a slow release opioid. What are your thoughts on that?
Caitlin Jones:
It's a very valid point. So the opal population had to have pain of less than 12 weeks duration, and the average pain duration was seven days. So that is probably a different population to those who show up at the emergency department who need their pain managed in a matter of hours rather than days. So Opal can't advise really on that situation. The opal results aren't directly transferable either because we've used the modified release drug. So that was mainly because it was the only formulation in Australia that had the naloxone, and I've talked about already why that was important. But we also didn't see that the, the, the cons of the modified release outweighed the pros for our purposes because it meant people could just take two tablets a day rather than every four hours, which we thought would increase compliance. And also after the first day or so when the blood concentrations are the same between an immediate release and a modified release, the effect was gonna be the same from our first time point, which was day one and onwards.
Caitlin Jones:
But they wouldn't be the same within a couple of hours after taking the first pill because you, you won't have reached peak blood concentration with a sustained release. There has never been a trial testing these immediate release opioids for this hyperacute severe pain in the ed. So it puts clinicians in a real tough spot where they're having to make clinical decisions without there being evidence for them to pull from. So it's another urgent gap that needs to be filled. And luckily some colleagues of mine are doing that trial at the moment, looking at back pain treated with opioid, with immediate release opioids and they'll have an answer for us hopefully soon.
Jared Powell:
Awesome. Yeah, so this, yeah, I mean, it all makes sense, right? You can't test and answer every question in one RCT. You had a very specific question and then a methodology to answer that question. And then the results I think are, are clearly reported. And of course, you know, we can say, well, what about this and what about that and what about that class of people and, and, and that class of patients and this class of drugs and blah, blah, blah, blah, blah. And that's all fair enough and valid, but, you know, and RCT is there to answer, especially an efficacy trial is there to answer a very specific question. And I think the trial did it pretty well and I think criticisms are valid and bring them on. And I think your response has been really, really good. So congrats to that. And also for surviving a fair bit of the, the backlash, which I can tell you from experience gets pretty intense there. So kudos to you.
Caitlin Jones:
Thanks.
Jared Powell:
I want, I wanna I wanna ask you what else are you working on? So you mentioned that your colleagues are working on a, a trial on a, on a immediate release opioid in, in a similar trial. What are you what are you working on? Anything cool coming up that we can keep an eye out for?
Caitlin Jones:
Yeah, yeah, I've got some cool things on the go. So another area where we suspect opioids might be being overused is in the post-surgical field area. So we're, I've just finished a pilot trial where we're, we're investigating whether the opioids that are given to people when they're discharged after having a hip or knee replacement surgery can be reduced a bit from what standard care is and whether people can have just as good pain management and, you know, return to function just as quickly, but maybe experience less of the side effects that we know come with opioid use. There's been some really good RCTs come out recently that have shown that opioids aren't any better than non-opioids for managing pain after surgeries that are, you know, sort of mild and moderate like hernia repairs and dental surgeries. But there's this big hole in the evidence when it comes to major surgeries like hip and knee replacements are known to be some of the most painful surgeries you can have. And yet we haven't had a, like, we haven't done a good job of looking into what the optimal pain management regimen is for these people that balances the need to manage pain, but also not have them experience more harms and side effects the necessary. Yeah. And our pilot work and also some other preliminary work in the field is, is really strongly hinting that we can probably be giving less than what we are giving without impacting people's pain control. So yeah. The next, that'll be the next trial I'll hopefully be working on
Jared Powell:
Looking forward to it. Yeah, prepare yourself. That's, it's, it's all as some assume there's gonna be some some interest in in that as well. So yeah. Prepare
Caitlin Jones:
Yourself. Yeah, I, I hope, I hope there's interest and yeah, I'll be, you're
Jared Powell:
Thick skinned now, caly.
Caitlin Jones:
Yeah, that's it. That's it. There'll be nothing quite like the first time, so, yeah. Yeah.
Jared Powell:
It's, when you mention, I'm just reflecting on some of my experiences in terms of going to the doctor and then, and this was maybe like a little while ago, 10, 15 years ago, maybe even more. I was a teenager a long time ago. Now you can, you, you go in for a sore throat and I, I remember one gp, a GP I think gave me Endone. Wow. I would've been maybe 18 or 19. And, and you know, you just go home and you, and you take it 'cause you numb the wiser at that point. And it was a bit of a wi I remember having these crazy vivid dreams and, and what have you after it, and it was a definite effect. And then that endone, I got so many of them, I took one maybe and I was better the next day anyway. 'cause It was a self resolving sore throat.
Jared Powell:
Yeah. Then it was just in my cupboard and I think it was there a year or two later and maybe I got, had a headache and I took, you know, so it's just there. And this is like getting all these tablets, maybe it was 12 and then they're just there in your house. There's something benign and innocuous I think. Is that, has that been kind of the, and maybe it's changed now. Has that been the, the, the prevailing practice that it's just given out too easy and too many and then they're just around and you can get addicted to them and the side effects? Is that narrative sort of ringing true?
Caitlin Jones:
Yeah, it definitely is. And I think you know, practice has tightened up over time where hopefully no one's giving endone for a sore throat anymore. But you know, especially in things like post-surgery, we do suspect there's still more tablets being given out than is necessary to manage people's pain. And, and after hip and knee replacement, for example, a a large portion of people have tablets left over like what you had after your, your sore throat. And they can cause harm because I think it's about 68% of opioids that get misused in Australia where acquired from friends or family. So it's someone who's had them left over, they're in the cover, they're in the bathroom, they end up in someone else's hands or, or being misused by someone in the household and they really can do some serious harm. So it's important that we're giving people the medicine to, that adequately manages their pain, but no more so that there's not these sort of leftover tablets out there to be misused.
Jared Powell:
Yeah, makes sense. Be judicious in the prescription and not sort of give access to people who don't need it. Mm-Hmm. May, you know, don't need it. You know, that's a strong statement, but who perhaps don't need it and might benefit for some other from, from some other medication, which might be just as effective for relieving their pain and not just, and not just having it lying around. Yeah, great point.
Caitlin Jones:
Yeah. And I, I think there's, you know, also long been a belief that opioids are the strongest painkiller and so the strongest pain needs opioids, which is is why they're, they're still so commonly used after surgeries, for example. But as we're going back and sort of doing the research that probably should have been done a long time ago, we are finding in a lot of different populations that opioids often don't offer more benefits than safer pain medicines. Like for example, we did a systematic review looking at all trials that compared opioids to non-opioids for musculoskeletal pain in the emergency department. And that included painful injuries like fractured femur, and there was high certainty evidence that nonsteroidal anti-inflammatories were just as effective compared to opioids, even for something like a broken thigh bone, a fractured femur. So this yeah, belief that, you know, opioids are the top notch painkiller I think is maybe starting to unravel a little bit. But yeah, more trials need to be done to know for sure.
Jared Powell:
It's interesting, these, these assumptions that we have in, in musculoskeletal medicine that are, you know, for, for lack of a better saying, old, old wives tales and, and myths that we have that just get perpetuated that have no evidence. And it's, it's mad to think about, and I very aware of the evidence when it comes to using exercise. So managing a lot of, a lot of different musculoskeletal ailments, low back pain, shoulder pain, what have you, and some of the, the flimsy evidence actually in support of exercise for a lot of conditions. And I kind of, when it comes to pharmacological management of musculoskeletal conditions, the evidence is far more robust and there's a lot of RCTs out there supporting the clinical decision making that doctors are making. And it's quite sobering to think that it's almost as bad in terms of an absence of evidence, what it's evidence-based medicine's been round for 20 or 30 years now Right. Since the nineties. And it's pretty crazy to think that your trial was the first that's been done using, comparing an opioid to a placebo for back pain and neck pain. Like what's the reasoning for that? We're just catching up. Do you think after all these years or?
Caitlin Jones:
Yeah, I think it's still catching up and in the field of opioids and, well, pharmaceuticals in general, there's this extra layer of marketing that has worked harder than, than evidence-based medicine over the last 30 years. And so this kind of disentangling marketing from evidence and really finding out where the gaps really are and then going back and filling them, I'm surprised too, you wouldn't think we'd be doing the World World's first anything in 2024, and yet some of the really most basic medical questions are still to be answered.
Jared Powell:
Yeah, it's I had Rochelle Bookbinder and Ian Harris on my last episode, and everyone should go listen to that. And their book mentions the medical industrial complex and, and the marketing that goes into it and perverse incentives and all of this stuff comes to dominate, you know, and you think that all these treatments are effective and medications are effective, and if you have back pain, take this pill or this combination of pills or do this stretch or exercise, and when you look at the actual RCT data, it's not there. And it, it does make you question a lot of what our, what our practice is based on. And like I said a moment ago, it's quite sobering and you feel for patients, you know, who are going through all of these things. Right. And they're being given advice from, well-meaning clinicians and doctors because they don't, you know, that's what the guidelines say and none of it's really tested. It's I guess I'm not asking for a solution here, Caitlin Mm-Hmm. But it's, it's a it's a strange place that we're in really.
Caitlin Jones:
It is. Yeah. And yeah, Rochelle and Ian's book hypocrisy, it's on my nightstand at the moment. It's a fascinating book and well worth reading that they, you know, lay out the complexity of this issue so well. Yeah. I really feel for patients because they're following advice from people that are also well-meaning I feel for clinicians too. Especially that, you know, e evidence-based medicine, like you said, is relatively new, and before that training was more like on an apprenticeship model, and so you spent years, decades training, you know, being taught by the people that came before you, what to do, and then to kind of learn in real time that maybe some of that hasn't been helping and maybe been harming. Yeah. It's difficult. And, and then as a clinician, like I did as an ot, you sort of become more and more aware of where the gaps are in the evidence and less and less confident about what to actually offer to your patients. Yeah. It's a bit of a spiral. It's not pleasant for anyone.
Jared Powell:
Yeah. I'm gonna be a, a bit vulgar and say it's a mind really, because Yeah, it's you, I've, I've gone through, you go through your training, you graduate, you start working for a few years, you think you got it all figured out. You start getting some results that don't fit the algorithm that you've got in your brain in terms of shoulder pain, do APEC stretch, you're better, low back pain, blah, blah, blah, blah, blah. You're better. And then you start investigating the evidence maybe, or you don't, or you keep your head in the sand and you just keep doing what you're doing. And perhaps that's a more healthier way to, to live your life. It's
Caitlin Jones:
More pleasant.
Jared Powell:
Yeah. Having a crisis of an existential crisis a few years out. It's a fascinating situation and I'm glad that you are doing the work and Rochelle's doing the work, and all these people around the world are doing the work and challenging these preconceived notions that we have because ultimately at the end of the day, you know, patients will benefit from these, these trials that we're doing. And we're going through this, this teething process where we're actually starting to vigorously and robustly test these common assumptions that we have. And often they're coming back null findings, same with many surgeries when we compare them to placebo surgeries, and we're starting to, you know, scrutinize our practice and that's gotta be a good thing, you know, like, that can't be a bad thing in totality.
Caitlin Jones:
Yeah, I agree. I agree. But you know, most people who become health professionals, whether that's doctors or allied health, do so because they wanna help people. Mm-Hmm. And yeah, it's really tough to learn somewhere down the line that yeah, some of the things we're doing aren't helping. And so I can understand some of the, the pushback and, and also the emotions involved in the pushback from a trial like Opal, because yeah, just preconceived ideas are unraveling left, right, and center and it's, it's uncomfortable for everyone. Yeah.
Jared Powell:
Hey, so it's good to be uncomfortable sometimes. All right, Caitlin, I'm gonna let you go, go to CrossFit maybe, or get back to work. Go fix the house or something. Where can people find you? Are you on, are you on, I know you're on Twitter. Do you mind giving out your Twitter handle or, or where are you at? Where can people find you?
Caitlin Jones:
Yes, I am occasionally on Twitter and you can find me at at Caitlin Jones underscore. I'm recently on LinkedIn, but not in any way that I know what I'm doing yet. So if you message me on their apologies that it'll be a, a little wait till I reply.
Jared Powell:
. Caitlin, thank you very much.
Caitlin Jones:
Thanks for having me, Jared.
Jared Powell:
Thank you for listening to this episode of the Shoulder Physio podcast with Caitlin Jones. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Turang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
