TREATING PAIN WITH NON-OPIOID MEDICATIONS

According to the National Institutes of Health, pain is the most common reason why people seek medical care.

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Daniel Berland, MD

“The prevalence of chronic pain in the U.S. is difficult to estimate, but its impact is profound,” says Daniel Berland, MD, clinical assistant professor of anesthesiology. “One hundred million Americans suffer daily pain symptoms, and chronic pain is the leading cause of long-term disability in our country. These numbers will only increase as our population ages, amplifying the need for effective, accessible interventions to manage chronic pain and preserve function.”

One common treatment for pain is the use of opioid medications, but these come at the cost of some patients becoming dependent or addicted, and sometimes opioids may be doing more harm than good.

“There are a number of patients who have opioid-induced hyperalgesia,” says Ronald Wasserman, MD, assistant professor of anesthesiology, service chief for pain medicine and director of the University of Michigan Back and Pain Center. “This patient group is on a higher dose of opioids, but is not responding. These patients tend to have more widespread pain, and the opioids are actually causing the increase and spreading of pain to happen.”

He adds, “Clearly we have an opioid epidemic in this country, so for this particular patient group, and others, our goal is to ease the patients’ pain and help get them off these high-dose opioids that could actually be causing them more pain.” The evidence showing opioids to be effective in the treatment of chronic pain is lacking, he notes, yet there are numerous studies showing the significant risks associated with opioids.

Wasserman and Berland work together at the U-M Back and Pain Center, which is part of the U-M Comprehensive Musculoskeletal Center. They utilize intervention techniques that do not include prescribing opioids to help ease pain for patients.

Berland explains that pain can often be effectively managed through non-opioid medications, as well as treatments such as injection therapy or other interventional procedures, surgery, physical therapy or psychological counseling, depending on the patient’s specific pain concerns and history.

“Pain is often a multidisciplinary problem that requires a multidisciplinary approach,” Berland says.

When Berland meets with new patients, he asks them how disabling their pain is, what they think brought on their pain and what has — and has not — worked in the past to manage it. By taking time to talk with patients, he explains, it’s not uncommon to discover underlying psychological sources for some of their pain.

“Several patients have had things happen to them in life that make them react abnormally to the pain they seem to have in their bodies,” he says. “It’s not because they’re crazy or they want disability, but instead, their brains have been altered by their lives.”

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Ronald Wasserman, MD

Wasserman agrees, “Patients take opioids for different reasons, and we continually take part in research to better understand why certain patients do better on these medications than others.”

Wasserman says there are current conversations at U-M about establishing a multidisciplinary opioid detox clinic dedicated to treating patients who are on high-dose opioids, either chronically or pre-and post-op, and weaning them down or off opioids. Such a clinic would include physicians, such as Berland, with expertise in the treatment of addiction and opioid dependence, as well as psychologists and a social worker.

Even if patients still need medications, a number of non-opioid options are available. Acetaminophen, such as Tylenol, and nonsteroidal anti-inflammatory drugs are commonly used for pain, although patients should continue to be monitored by a physician, as excessive doses can cause liver or other gastrointestinal problems.

Berland says additional adjuvant medications can be used alone or in combination with other pain relievers. For example, several classes of antidepressants and anticonvulsant medications have proven effective for some types of pain, while also potentially benefiting mood and sleep.

For pain specific to one area, he adds, pain relievers can sometimes be delivered to a particular location through patches, injections or ointments. Some patients, paradoxically, do better once they are weaned from existing pain medications. Although they are not covered by insurance, mindfulness techniques, such as meditation, have been shown in some studies to help control pain response, moods and sleeplessness.

It’s important for patients, working with their care providers, to set realistic treatment goals for functional improvement.

“While complete pain relief may not be possible, effective therapy should control pain in order to improve a person’s functioning at work, home, in social situations and while pursuing preferred activities,” Berland says.

Sidebar:

100 million Americans, or 43% of the U.S. population, suffers some sort of daily pain.

Chronic pain is the leading cause of long-term disability in our country.

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