As Addiction Rises, Doctors Seek Pain-Relieving Alternatives to Opioids

Doctors seek new paths toward pain relief amid an epidemic of addiction and death.

As an alternative to opioids, pain-management specialists can utilize a variety of injections. Some target pain trigger points, such as knotted muscles. Others, known as epidurals, are used to reduce pain emanating from the spine.
As an alternative to opioids, pain-management specialists can utilize a variety of injections. Some target pain trigger points, such as knotted muscles. Others, known as epidurals, are used to reduce pain emanating from the spine.
Photo by Fred R. Conrad

At 25, the young woman had already been through a hellish series of medical crises: tumors on her adrenal glands that caused her weight to double and her blood pressure to surge; surgery to remove the tumors; another procedure to repair an abdominal aortic dissection—a tear in the body’s largest artery, often caused by hypertension; a postsurgical infection that eventually led to the removal of 2½ ribs; and then months of grinding chronic pain.

Eventually, the Camden County resident found a pain doctor who put her on a combination of two powerful opioid medications, fentanyl and Percocet, and for eight years, she was able to live something close to a normal life—not free of pain, but not enslaved by it either. But given the growing crisis of opioid abuse and the resultant calls to cut back on the prescription of opioids, Marie, as she’s asked to be called, worries that she could once again find herself living in a world of pain. “I fear that, at any time, they’re going to pull my medication,” she says, “and I don’t know what I’ll do.”

There’s another side to this story, of course, and it involves the thousands of Americans whose lives have been upended—or simply ended—by the abuse of opiates, drugs such as morphine, codeine and heroin, which are derived directly from the opium poppy, and opioids, synthetic drugs that work in similar ways. These include methadone, oxycodone, hydrocodone and fentanyl.

Opioid abuse—implicated in the deaths of more than 30,000 Americans in 2015—has been declared a national health crisis. In 2015, New Jersey’s death rate from opioid overdoses was 18.1 per 100,000 people, or 1,587 deaths, according to the New Jersey office of the attorney general.

Chris Christie, in his final year as governor, has made the opioid crisis his signature issue. In September, he rolled out a $200 million plan to deal with the state’s addiction epidemic. The plan emphasizes treatment and relapse prevention.

Thanks to concern about potential addiction and overdose, along with state laws regulating prescription opioids (New Jersey’s rules, enacted this year, are among the nation’s strictest), physicians are writing fewer prescriptions for the drugs. And the crisis is forcing patients and doctors alike to seek alternative ways to manage pain.

Three decades ago, managing pain wasn’t a high priority for most physicians. That changed in the mid 1990s, thanks to a confluence of factors. At the 1995 conference of the American Pain Society, in response to a growing sense among physicians that chronic pain (defined as pain lasting longer than three months) was being grossly undertreated, a neurosurgeon named James Campbell argued that pain should be considered a vital sign along with temperature, pulse, breathing rate and blood pressure. In the offices of neurologists and general practitioners alike (not to mention dentists, many of whom liberally prescribed opioids after commonplace surgical procedures like root canal and tooth extraction), physicians began to focus not just on alleviating pain, but on eradicating it completely.

Around the same time, a small Connecticut-based pharmaceutical company, Purdue Pharma, introduced a painkiller they called OxyContin, a timed-release version of oxycodone. Purdue’s sales reps pushed the opioid hard, their pitch bolstered by the claim—now disproved—that the drug wasn’t addictive when administered to pain patients because of its controlled-release feature. Doctors seized on the good news, prescribing OxyContin and other opioids for everything from headaches to back spasms.

One early indicator of the problem came when an employee at Washington State’s Department of Labor and Industries noticed that an alarmingly large number of injured workers in the state’s workers’ compensation system were dying of opioid overdoses. In 2005, a published study regarding the Washington trend triggered concern throughout the medical community that opioids prescribed for pain might, indeed, be addictive; further, they could be deadly. Meanwhile, patients who’d become addicted turned in larger and larger numbers to an opiate that was considerably cheaper and newly plentiful: heroin. In 2008, for the first time, drug overdoses, mainly from opioids and opiates, surpassed automobile accidents as the leading cause of accidental death in the United States.

Suddenly, doctors were reconsidering their approach to pain, and government agencies were issuing strict guidelines for the prescription of opioid medications. Last year, the Centers for Disease Control released a list of 12 recommendations aimed at primary care doctors, who account for almost half of all opioids prescribed. The CDC urged doctors to treat chronic pain, if possible, with nonopioid medications, prescribe the lowest possible dose, and closely monitor all patients treated for pain. In New Jersey, the new opioid-prescription law requires, among other things, that initial prescriptions for opioids in the treatment of acute pain don’t exceed more than a five-day supply and that longer-term prescriptions be limited to a 30-day supply. (Cancer and palliative-care patients are exempt from the law.)

With the revelations about opioids, doctors began searching for ways to treat pain with lower dosages of the drugs (or none at all), some even questioning whether the goal of eradicating pain itself was plausible.

“That’s called ‘reasonable expectations,’” says Dr. Marcello Sammarone, a pain-management specialist in Parsippany. Sammarone routinely cautions his patients that they should not expect their pain level to drop to zero, referring to the familiar pain scale through which patients rate their discomfort from zero to 10. “I tell them,” he says, “that the goal is to bring down their pain intensity to a five.”

Rethinking pain is only one of many strategies doctors are turning to in what could become the post-opioid age. In fact, most pain specialists employ a multimodal approach, combining an array of therapies to attack pain on a variety of fronts.

“We want to try to target the pain pathways from multiple perspectives,” says Dr. Jeffrey Gudin, medical director of pain management and palliative care at Englewood Hospital and Medical Center. Gudin is referring to the routes through which pain signals travel from their source in the body to the brain and back again. Patients suffering from musculoskeletal pain, for instance, might be prescribed an anti-inflammatory like ibuprofen, a muscle relaxant like diazepam, and a topical analgesic such as lidocaine or capsaicin; they might receive injections of a nerve-blocking agent or a corticosteroid to decrease inflammation; and they might also be instructed to make lifestyle changes involving exercise and weight loss and be directed to a physical therapist and/or a psychologist specializing in pain. Ultimately, the decision about which methods to employ depends on the individual patient and the nature of his or her pain.

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