Alternatives to opioids
By Anita Peltonen
If you have bad pain but want to know if you can avoid opioids, ask your doctor. Each day, armies of researchers smash the borders of their own understanding of pain and how our brains process it. Their discoveries seep down slowly to civilians, however.
You won’t find many of the game-changers in “ask your doctor” TV ads, because they involve highly specialized ingredients or techniques.
For example, if you have joint pain, ask what the doctor has to say about the chili-pepper extract capsaicin, which in its pure form rates 16 million Scoville Heat Scale units. Tabasco’s around 300. New trials using a capsaicin-like compound from a Moroccan desert plant clocks in at 1.6 billion SHS units — and aims to soothe intractable cancer pain.
Cryotherapy, meanwhile, uses localized freezing to deaden irritated nerves. And in cool, dark rooms within a small number of rehab facilities, a virtual reality platform called CAREN (computer-assisted rehabilitation environment) helps recondition wounded soldiers or depleted astronauts and is slowly becoming available to the general population.
While such remedies hold great promise for severe pain patients, safety-testing often puts a long hold on innovative treatments.
Slow to market
A decade ago, a dog had a tumor in his forepaw so painful, he couldn’t walk. His owner took him to a National Institutes of Health animal trial for cancer pain. Using a “molecular scalpel” (a fluid injection), a medical team permanently turned off the neurons flooding 90-lb. Scooter’s system with pain signals. The team used the capsaicin-like compound to get the relief response.
Afterward, Scooter walked again. More large dogs were helped by the procedure, a landmark in silencing primary pain receptors. Anesthesiologist Andrew Mannes, the lead doctor on this NIH research, speaks quietly, but telegraphs urgency when he describes the likely first human beneficiaries. “End-of-life patients. One of their greatest fears about the end of life is: Will this be painful? This is compassionate use.”
Human trials began in 2015 and should conclude in December. Meanwhile, pain patches using capsaicin come in varied strengths for over-the-counter and doctor-supervised use.
The day doctors vanquish pain seems tantalizingly near.
Until then, innovative chronic-pain management may use established opiate and nonopiate painkillers, but for shorter durations and in concert with bodywork like physical therapy, shockwave therapy, or the lesser-known Graston technique.
A bit like surgery over the skin (this reporter was treated successfully with Graston at Adirondack Medical Center, Lake Placid), the Graston blades are drawn firmly across pain points by a trained PT. This creates a micro-trauma that sparks fibroblasts (healing cells) to break up internal lesions and scars left by chronic inflammation. Case studies show Graston’s very good for curing Achilles tendinopathies.
Let me tell you: It’s not for wimps; Graston feels like a bear’s trying to iron you flat with his claws. But it was worth it.
More plant plays
Capcaisin 8% topical patch Qutenza emerged from the research used to help Scooter. It must be administered “under the close supervision of a physician,” notes the National Center for Biotechnology Information, and “no sooner than once every 3 months.”
Such patches — another type contains anesthetic lidocaine — can be put over afflicted joints or muscles, and deliver relief superior to pills, often without the organ stress that can accompany long-term pill use. The narcotic fentanyl comes in a patch, too, but the Mayo Clinic warns it “is only used for opioid-tolerant patients. A patient is opioid-tolerant if oral narcotics have already been used for severe pain.”
Non-surgical and IV options
Familiar drugs like acetaminophen can be used intravenously, reports Pain Management Nursing journal, without the side-effects of opioids (nausea, respiratory depression), “or the platelet dysfunction, gastritis, and renal toxicity … associated with non-steroidal anti-inflammatory drugs,” like ibuprofen. And IV acetaminophen “is the only approved IV non-opioid analgesic … indicated for use in pediatric patients.”
Dental pain inspires fear in most people, yet Dr. Brian Bateman, of Brigham and Women’s Hospital, Boston, tells WebMD, “non-opioid [painkillers] may be more effective” in dental-surgery settings than opioids.
What more needs fixing
Sen. Kirsten Gillibrand (D.-NY) bullet-points stark drug-abuse facts on her website: “Between 1999 and 2010, there was a 400% increase in sales of prescription opioid pain relievers in the U.S. … [but there has] not been an increase in the amount of pain Americans report, according to CDC [Centers for Disease Control and Prevention].”
Gross numbers overlook individual realities and complexities. Of the 100 million Americans in chronic pain, some have well-controlled pain. But a vast number don’t get relief, according to the National Academies of Science.
Even in hospitals
The charity Pain News Network found that among 1,250 hospital patients, “over 52 percent said their pain treatment in hospitals was poor or very poor, 25 percent rated it fair, and only 23 percent said it was good or very good. Many patients complained that their pain went untreated or under-treated, even though pain was usually the primary reason they were admitted to a hospital.”
Beware pain-pill mills
Consumer Reports, in the cover story on dangerous doctors in its latest issue (May 2016), cites a neurologist called out for “allowing unlicensed medical assistants to routinely give patients narcotic painkillers through infusion pumps; in one case, a woman was sent home after receiving more than four times the proper dose.” The magazine says the woman died the next day.
While primary physicians prescribe half the opioids in the U.S., according to CDC, they receive on average just 12 hours’ pain training at medical school. For new generations, this will increase. But with pressure to dial down opioid supply, practicing doctors should increasingly start sending chronic-pain patients to specialists.
Mental health piece
Finally, what are the alternatives for non-addicted local pain patients when they want to clear their brains and bodies of opioid and CNS drug use, maintain pain management, and receive withdrawal care?
Writes Melanie Thernstrom in The Pain Chronicles: “There is increasing evidence that … untreated pain eventually rewrites the central nervous system, causing pathological changes to the brain and spinal cord, and that these in turn cause greater pain.” Such patients are sometimes told there is nothing quite right for them. Psychiatric nurse Rita Kimball, who sees chronic pain and other patients in Wappingers Falls, says, “General practitioners think of places for addicts. You would need a medical detox. You can’t stop opioids precipitously.”
Medical detox facilities in our region are Arms Acres in Carmel and Turning Point at MidHudson Regional Hospital of Westchester Medical Center in Poughkeepsie (formerly St. Francis Hospital) , Kimball says.
She hopes that pain doctors will monitor patients’ mental health, too, since “we know that pain and depression involve the same part of the brain. When you become depressed after being in pain and knowing it is not temporary or is maybe forever, that is pretty daunting.” In some cases, patients become suicidal, and then, sadly, quietly, almost invisibly, join the rising opioid-death count. For that, surely, more alternatives must come to the fore.
Physical treatment of pain
Cold Spring Physical Therapy’s John Astrab, who holds a doctorate in physical therapy, treats patients who are being medically managed in many different ways. “I would just move a little slower with patients on opioids and CNS [central nervous system] drugs, for their safety,” he says. “Their chemistry is in flux from the drugs.” The more ingredients in the mix, the harder it is to chart progress. “You have to factor in their individual metabolism.”
“If you take drugs that change the central nervous system, it will affect other systems in the body. It can suppress them,” he says, adding, “If our appetite is suppressed, how can we nourish ourselves in order to heal?”
Why do many doctors and patients go to opioids instead of therapeutic body work? “Somewhere along the line, that other option [opioids] becomes too easy a choice — a quick fix,” he says. “We need to treat the root causes instead of focusing on the symptoms.”
But that kind of fix may not last, as the body can develop a tolerance to medicines. And they may ultimately weaken, not strengthen, the pain patient. Movement, however, stops the body’s deconditioning, lets the body and brain’s self-healing mechanisms work, and helps stave off the depression that often springs from chronic pain.
The most potent ways to deal with pain, says Astrab: Manual therapy, including but not limited to physical therapy, massage therapy, chiropractic or acupuncture; patient education in posture, activity modification, self-management, ergonomics; and lastly therapeutic exercise. Movement needs to be specific and individualized. In some cases we need to stabilize, but in others we need to mobilize healing tissues.
Beacon’s Elizabeth Castagna teaches the extremely gentle Alexander Technique to help re-align the spine. “It’s a process that allows you to coordinate mind and body to re-learn movement, deepening our understanding of how we’re designed to move,” she writes at elizabethcastagna.com.
For high-level back discomfort, devices like pumps, epidurals and pulse emitters are increasing anti-pain arsenals at specialized pain centers like Robert Wood Johnson Hospital in Rahway, New Jersey.
For lower extremity pain, podiatric surgeons are increasingly giving non-surgical consults. They’re sought after by people who have been or fear becoming failed-surgery patients. Instead they may be offered improved walking casts and a course of simple exercise.