February 2019, Volume XXXII, No 11
Dialing down opioid use
he opioid crisis currently gripping the U.S. presents significant challenges for the treatment of chronic pain. For much of the 2000s, opioids were liberally prescribed to treat pain, but in recent years, it has become clear that prescription opioids may lead to abuse, addiction, and overdose death in a certain population of chronic pain patients. The risks associated with opioid treatment have forced patients dealing with chronic pain—and physicians attempting to treat that pain—to look for alternative treatment options. Fortunately, a variety of alternative, non-addictive pain treatments are available and will be discussed in this article.
In the 1990s, the under-treatment of acute and chronic pain in the U.S. became recognized as a major public health problem. In response, Congress ushered in the “Decade of Pain Control” in 2000 at the same time that health care regulators designated pain to be the “Fifth Vital Sign” and prominent physicians advocated for more liberal opioid prescribing. This trend toward more aggressive pain management was bolstered by the pharmaceutical companies as they developed and marketed powerful new opioid formulations. As a result, from 2000 to 2010, the rate of opioid prescribing, the number of opioids distributed, and the average prescription size all increased markedly as deaths from opioid overdoses ramped up in parallel.
By 2012, the U.S. was in the midst of a full-blown opioid crisis that persists today. According to the recently published Surgeon General’s Spotlight on Opioids, opioid overdoses killed more than 48,000 Americans in 2017, and deaths from opioids in the U.S. have surpassed deaths from motor vehicle accidents and shootings combined in every year since 2013. Although illicit fentanyl is now a major contributor to the current crisis, prescription opioids administered for pain have been implicated in causing the addictions that have led to many opioid overdose deaths.
Patients with chronic pain present with a broad continuum of different problems, ranging from nociceptive (biological) pain caused by severe inflammatory conditions like rheumatoid arthritis, to neuropathic pain caused by damage to the nervous system, to pain behaviors driven primarily by psychological mechanisms and personality disorders. Sorting out the causes for chronic pain and developing an effective treatment plan are challenging tasks for physician pain specialists. Regardless of the cause for pain, it has become increasingly apparent that prescribing opioids to treat chronic pain may lead to addiction in susceptible patients and overdose death in some of these patients. And most experts agree that the liberal opioid prescribing practices of the past have contributed to our current national opioid crisis.
There are now alternatives to opioid management for chronic pain.
Integrating non-drug treatments
If medications are not adequately controlling pain or are causing untenable side effects, interventional techniques can be utilized for those patients with identifiable structural abnormalities contributing to pain. The goal of the interventional pain specialist is to identify the physical generators of pain and to precisely target and treat them to the greatest extent possible using image-guided, minimally invasive procedures. At Nura, we coordinate interventional procedures with physical therapy and behavioral health treatments as necessary for a comprehensive, multi-point approach. For those who fail to respond to therapeutic procedures, physical therapy, and behavioral health treatments, we consider implantable pain control options.
We believe in moving from simple to more complex treatments as necessary to reach our goals of reducing pain and improving function. For those patients who respond to non-addictive medications, physical therapy, chiropractic adjustment, and/or complementary medical treatments such as acupuncture, we encourage the patient to continue these low-risk therapies. For pain that does not respond to conservative, non-invasive treatments, we first consider diagnostic and therapeutic procedures such as targeted spinal steroids and radiofrequency nerve ablations. When these minimally invasive procedures fail, we consider implantable pain control systems as last-resort alternatives to long-term oral or skin patch opioids.
Implantable pain control options include spinal cord stimulators that generate electrical signals to block pain transmission in the spinal cord and pain pumps that block pain receptors within the spinal cord using small doses of targeted medications delivered by an intrathecal catheter. Both options involve a trial of the therapy and, if successful, a minimally invasive outpatient surgery to implant the permanent delivery system. Spinal cord stimulation is often tried first because it is an epidural system that is not in direct contact with the spinal cord and does not involve medications. Pain pumps are somewhat higher risk because they utilize an intrathecal catheter that deposits medication directly onto the spinal cord to provide targeted drug delivery (TDD).
There is no addiction potential with pump opioids.
David Schultz, MD, is the medical director and founder of Nura pain clinics. Dr. Schultz is a board-certified anesthesiologist with additional board certification in pain medicine from the American Board of Anesthesiology, the American Board of Interventional Pain Physicians, and the American Board of Pain Medicine. He has been a full-time interventional pain specialist since 1995. He is past president of the American Society of Interventional Pain Physicians (ASIPP) and has taught physician courses in the field of interventional pain management for the past 25 years as an instructor and course director for ASIPP, International Spinal Injection Society (SIS), Medtronic, and Abbott. He is a prolific author of clinical articles and book chapters, a frequent speaker at national meetings, and a principal investigator in pain research.