Time to Clean Up the Mess
Clinical experts weigh in on what’s next for pain management.
By Mark Pew
It’s indisputable that society has recognized the overuse, misuse, and abuse of opioids since Big Opioid Pharma convinced prescribers, pharmacists, and medical schools that they would solve the pain problem.
The federal government took notice and responded via the Centers for Disease Control and Prevention’s formal declaration of an “opioid epidemic,” and later publishing of prescribing guidelines. Additionally, U.S. Surgeon General Vivek Murthy launched the #TurnTheTide initiative and sent a letter about the addictive nature of opioids to every doctor in the country. Individual states responded by legislating maximum day supplies, expanding access to naloxone, encouraging substance abuse treatment, and mandating the use of prescription drug monitoring programs. The media—mainstream and social—noticed and regularly publishes statistics and individual stories about the devastating impacts of opioids and other dangerous prescription painkillers.
So if the country knows that opioids are dangerous, how will non-malignant chronic pain (NMCP) be treated in this changing landscape?
There are a limited number of situations in which opioids are clinically appropriate for NMCP. These are cases in which the lowest possible dosage and number of drugs yield acceptable levels of activity and function with a manageable set of side effects. The general consensus is that opioids can improve function by about 30 percent in the best-selected candidates. That means opioids are not appropriate treatment for the majority of people with NMCP. So what’s next?
To get a well-rounded view, I surveyed several clinical experts around the country who are highly respected for having the proper approaches and consistently high-quality outcomes. The list included clinicians (six doctors, two psychologists, and three nurses) who directly help patients deal with pain, and three medical directors of workers compensation payers.
While all of the respondents agreed that opioids have been overused for NMCP, not all of them made the same suggestions. It is entirely possible that some would even disagree with some of the recommendations. The bullet points below are a synthesis of respondents’ input and should be viewed as potential tools in the overall toolbox. Individualized treatment for NMCP can be complex, so the treatment provider needs to have access to as many options as possible to determine which ones work best for a person’s specific conditions at a given point in time.
Here are the respondents’ answers to the following four questions.
1. What are the most appropriate prescription drug options for chronic pain in lieu of opioids?
Respondents’ Summary: There is no “magic pill,” and, increasingly, studies show that medications should not be the primary management tools for pain. That said, the following may be helpful in some circumstances and for certain types of pain:
• Acetaminophen and NSAIDs like celecoxib, ibuprofen, ketoprofen, meloxicam, and naproxen.
• Antidepressants, particularly tricyclic antidepressants and serotonin and norepinephrine reuptake inhibitors, like amitriptyline, duloxetine, and trazodone.
• Anti-convulsants, like gabapentin, pregabalin, and carbamazepine.
• Topicals that include ingredients like lidocaine, NSAIDs, and capsaicin.
• Muscle relaxants for nocturnal use only, like cyclobenzaprine, baclofen, and tizanidine.
• Tapentadol, which has much lower risks and side effects than tramadol or other opioids.
• Buprenorphine (some respondents said this could be a maintenance medication; others thought it should only be used during the opioid tapering process).
• Definitely NOT carisoprodol or any benzodiazepines like alprazolam, clonazepam, diazepam, lorazepam, or temazepam.
Note that all of these drugs have potential negative side effects, many should not be used long-term, and several have a risk for misuse, abuse, or addiction. In other words, everything should be done to limit or even eradicate the number of medications used to manage NMCP.
2. What is the easiest non-prescription drug option to implement in parallel with the reduction or elimination of opioids?
Respondents’ Summary: If they work, non-pharmaceutical options will always be better for a patient’s short- and long-term health. However, the term “easy” is relative, as it is easier to suggest treatments than it is to get patients to truly believe that they will work and to be consistently motivated to continue them for the rest of their lives. While some of the suggestions include temporary modalities to reduce pain, most revolve around making lifestyle changes that are lifelong and self-sustaining. Sometimes it is difficult to motivate patients because the suggestion seems foreign or even implausible and might require a switch from a dependence mindset to one of independence and resiliency. Everything listed is either supported by evidence or by clinicians’ personal experiences. Suggestions include:
• Individual responsibility for maintaining one’s own health to move from injury mode to recovery mode.
• Ice and heat.
• Active exercise treatment plan for progressive aerobic and physical strengthening, which not only stimulates the body, but also the brain.
• Healthy diet and nutrition plan, with a focus on anti-inflammatory and low-acid foods, daily hydration, moderate carbohydrate load, sugar avoidance, and limited caffeine and alcohol.
• Physical therapy, including hydrotherapy and posture correction.
• Psychotherapy, including cognitive and dialectical behavioral therapy (this was mentioned by all as the fastest and longest acting non-pharmacological method to deal with NMCP).
• Mindfulness practices, meditation, and guided imagery.
• Fear avoidance belief training.
• Life coaches.
• Deep breathing maneuvers.
• Yoga, Tai Chi, Nia technique, and Qigong.
• Relaxation response training and biofeedback.
• Smoking cessation and weight loss.
• Chiropractic treatment.
• Massage therapy.
• High-frequency neurostimulation.
• Transcutaneous electrical nerve stimulation.
• Low-level lasers and electromagnetic therapy.
• Nerve blocks and injections, although these procedures are costly and success is highly dependent upon locating a specific pain site and the physician’s skills.
3. What is the most long-lasting, non-pharmaceutical option for managing chronic pain?
Respondents’ Summary: While the modalities listed previously are the tactics, there were some specific strategies that create some guiding principles, including:
• Educating the patient on the best way to self-maintain the proper attitudes about NMCP and then finding the most appropriate treatment options that can be self-sustaining. The formula for each person varies, but it starts with the concept that pain may be the “new normal” and there is no quick fix. Patients also need to understand pain signaling, the role of deconditioning, and the importance of trying various modalities.
• Establishing an ongoing lifestyle of activity and exercise, good nutrition and eating habits, and proper sleep hygiene. In other words, helping the patient consistently make better lifestyle choices to improve and maintain their health.
• Developing resiliency and a determination to not allow pain to turn into suffering. Taking active control of the pain as opposed to having a passive expectation that someone or something else will eradicate the pain. Being happy, keeping busy, and not focusing on the pain. In other words, equipping patients with the ability to cope with the pain.
• Establishing relationships with mentors and fellow NMCP patients for accountability and support.
4. What do you anticipate doctors will do when opioids are no longer an option (for whatever reason)?
Respondents’ Summary: Doctors will gravitate towards what will be paid. In other words, the navigation towards different strategies largely will be dictated by the payers. However, it will also require teamwork with the medical community. Several respondents pointed out that many physicians either do not understand or do not want to treat NMCP because it’s challenging, individualized, and potentially requires an “all-of-the-above” trial and error approach that can be time consuming and not appropriately reimbursed. All hoped that the treatments listed above would not only be used, but also paid for in increasing measure to help foster a focus on functional restoration and recovery.
There was consensus among respondents on the majority of suggestions because evidence-based medicine confirmed the approaches. However, there were some unique perspectives. One respondent noted that there is an industry built on the continuation of pain, which may, in fact, be the biggest obstacle to properly treating NMCP. Two said that medical cannabis has evolving evidence (including recent research from the National Academies of Sciences, Engineering, and Medicine) that point to its benefits in treating chronic pain. One suggested that an educated consumer with money at stake through out-of-pocket payments would help focus choices. Another noted that workers compensation has been unwilling to fully embrace the biopsychosocial model because it could potentially bring with it the psyche diagnosis that opens up liability for even more costs and scope of services. All of those points certainly bear consideration.
Acute pain is obviously different than NMCP and requires different resources. Opioids could be part of that pain management process for a short time. As a potential model, one of the respondents explained her regimen for a recent hip replacement surgery. Three days after surgery, she took two ibuprofen 200mg pills every four hours, two acetaminophen 500mg pills two hours later, then alternated between them every two hours along with an opioid at bedtime (in lieu of the acetaminophen) to assist in restful sleep. She took a total of three opioid pills after that third post-surgery day. Unfortunately, that is often not the regimen seen in medical and claims files.
Clearly, what’s next for pain is thinking about it differently. Patients, clinicians, and payers need to be willing to try and pay for different treatments. Treating NMCP is complex, but the common theme among these clinicians was that a mindset of resiliency and recovery coupled with as few medications as possible is a better approach than what has evolved since the mid-1990s. In order to create that mindset, more time must be allowed in each office visit for the doctor to understand the person and utilize the options that actually work.
It would be patently unfair—in fact, it would be inhumane—to swing the pendulum to the other extreme of “no opioids” without providing access to other methods by which to manage NMCP. It is obvious that opioids are, in many cases, more dangerous and create more issues than the original source of pain. As the U.S. healthcare and workers compensation systems deal with how to #CleanUpTheMess, not being constrained by the old way of doing things is a necessary first step.