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

Michael Cooney, a chiropractor in Rutherford, uses Calmare therapy to treat patients with painful neuropathies. The Calmare device uses electrodes to “reboot” the brain so that it is no longer aware of the pain. Relief can range from 6 to 18 months or longer. Photo by Fred R. Conrad

Nonopioid Medications
Increasingly, pain doctors are following what Malik calls “a rational, cautious, sensible medication treatment strategy.” That means starting with the most conservative therapies first. Anticonvulsants like gabapentin and pregabalin (Lyrica), for instance, have proven effective in managing neuropathic pain. A variety of antidepressants, including duloxetine (Cymbalta), amitriptyline (Elavil) and nortriptyline, have been shown to moderate pain. And topical analgesics, like the numbing agent lidocaine and the nonsteroidal anti-inflammatory diclofenac, can be applied to the skin directly over the site of pain and don’t carry the same side effects as their oral counterparts.

Short-Term Treatment
The push to cut back on the prescription of opioids extends beyond the realm of chronic pain to the treatment of acute pain, both after surgery and in the ER. Surgical patients are increasingly likely to be sent home with prescriptions for nonopioid medications like nonsteroidal anti-inflammatories and other nonnarcotic analgesics like acetaminophen. And in some cases, even perioperative pain (pain before, during or after surgery) is being treated without, or with minimal, opioid medication. In an opioid-leery era, it’s critical for patients to talk to their surgeons about pain relief before surgery to ensure that postsurgical pain is well controlled.

An important question to ask is whether the surgeon and the hospital follow a protocol known as ERAS (Enhanced Recovery After Surgery). Designed to minimize the use of opioids and at the same time maximize recovery and postoperative comfort, ERAS generally involves the use of nonnarcotic pain relievers, not just after surgery but also before and during a surgical procedure (sometimes in combination with a nerve block). Under ERAS, patients are frequently encouraged to drink clear liquids containing electrolytes and carbohydrates up to two hours before surgery and to be up and walking within 24 hours. ERAS patients take fewer opioids, mobilize sooner, do better in physical therapy, discharge faster and recover more quickly.

Like surgeons, ER doctors are cutting back on the use of opioids for acute pain. In fact, hospital emergency departments have long been the favored source for drug shoppers—addicts who visit multiple ERs to score opioids—a situation that’s put them on the front lines of the opioid crisis.

“I would say that all emergency departments over the past 10 years have faced up to the opioid epidemic and really tried to be very thoughtful about their prescribing habits,” says University Hospital’s Nelson. Previously, after a visit to the ER for a sprained ankle, you might have been sent home with enough opioids to get you through the healing process and, as Nelson says, “tide you over for a rainy day.” That’s far less likely to happen today. In fact, he notes, while a severe injury will still be treated with opioids, that ankle sprain is more likely to get you some acetaminophen or ibuprofen plus an ice pack and a compression bandage.

A few New Jersey emergency departments have gone even further. In January 2016, the ED at St. Joseph’s Regional Medical Center in Paterson was the country’s first to adopt a program known as ALTO, for Alternatives to Opiates. Rather than prescribe potentially addictive narcotics, the doctors at St. Joseph’s rely on injections, dermal patches and nonnarcotic painkillers to treat acute pain. (In July 2016, the AtlantiCare health system, based in Atlantic County, adopted the ALTO approach as well.)

The Opioid Conundrum
Not everyone thinks that doing away with, or severely limiting, opioids is a good idea. Like Marie, many patients with severe, chronic pain believe that, without the drugs, their lives would be unlivable. Some doctors agree.

“Come spend a day in a pain center,” says Gudin, “and every single patient will say, ‘I don’t understand why my dose is being lowered—I was doing fine on my medicines.’”

Gudin calls federal and state dosing limits arbitrary. “If we had other successful or efficacious treatment options,” he adds, “we wouldn’t have to rely on the opioids—but that’s not the case.” Sammarone believes that responsible pain specialists shouldn’t be blamed for the opioid epidemic. “The crisis that we’re having now,” he says “isn’t as much from pain-management doctors, but from doctors without the qualifications and training to go to the source of the pain to eliminate the problem.”

At the other end of the spectrum are those like Chetan Malik, who question the very efficacy of opioids. Malik calls them “a failing therapy,” noting the paucity of studies showing that opioids are actually effective at controlling chronic pain. He says opioids may actually increase pain in the long run. A 2016 study out of the University of Colorado at Boulder bears out his claim. It showed that the opiate morphine significantly prolonged pain in mice, compared to a control group that received no morphine.

If the opioid crisis has done anything positive, it’s to have created this debate in the first place. More studies on the effectiveness and best use of opioids should follow, along with the development of better, nonaddictive treatments for pain. Until both of those things occur, though, the scales are likely to seesaw relentlessly between the need to curb opioid abuse and the desperate needs of people in pain.

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Leslie Garisto Pfaff is a longtime contributor specializing in health care and education reporting.