“Patients on opioids often are surprised that they can get similar, or even greater, pain relief on lower doses of opioids or even off opioids completely. But this often requires a comprehensive approach to provide sufficient medical, psychological and behavioral support while they slowly taper the opioids.”
In response to a national epidemic of prescription opioid addiction, the U.S. Centers for Disease Control and Prevention has issued guidelines designed to reduce inappropriate prescribing of narcotic drugs for noncancer chronic pain. UCLA Health pain-management specialists note that non-narcotic approaches to treating chronic pain not only are safer, but also in many cases more effective.
“Opioids are appropriate for cancer, end-of-life and short-term pain, but they never should be used as a first-line treatment for ongoing pain,” says F. Michael Ferrante, MD, director of the UCLA Comprehensive Pain Center.
Approximately 25-million adults in the U.S., one-in-nine, have experienced some ongoing form of pain, according to the National Health Interview Survey. Beginning in the late 1980s, opioid medications began to be prescribed for many types of chronic pain. But that thinking has changed as awareness of addiction has increased. “The number of people dying from overdoses of prescription medications is now considerably higher than the number dying from illegal drugs,” notes Michael Sniderman, MD, a UCLA painmanagement specialist in Torrance. (UCLA Health also has community-based pain clinics in Santa Clarita and Thousand Oaks.)
Dr. Ferrante says that patients who seek opioid medications tend to fall into four categories: those who can use them effectively on a long-term basis to improve their quality of life with no major complications; those who develop opioid-induced hyperalgesia, needing increasingly higher doses; those who become addicted and in need of rehabilitation; and those who should never receive the drugs.
“An evaluation that includes experts in pain, addiction and psychiatry can help to determine into which category a patient falls. You have to tailor the alternatives based on the underlying cause of the pain,” Dr. Ferrante says.
Some patients can benefit from nonopioid medications such as anti-inflammatory drugs, particularly patients with bone pain, Dr. Ferrante notes. Acetaminophen can also be used, but in moderation — no more than 2 grams per day for chronic use.
So-called interventional procedures can also provide relief. Depending on the source of the pain, these can include facet joint injections as well as injections that block the responsible nerves from sending pain signals — in some cases in conjunction with radiofrequency ablation, which uses electrical currents to heat targeted areas in an effort to further decrease the signals. “Over the years, the ‘interventional pain doctor’ role has grown significantly as problems associated with opioid medicines have become better appreciated,”
Dr. Sniderman says. Drs. Sniderman and Ferrante note that these interventional procedures, coupled with physical therapy and/or occupational therapy, significantly reduce pain and improve function. “We can make it easier for patients to do the kinds of physical therapies and exercises that might heal them for the long term,” he says.
Says Keith Heinzerling, MD, addictionmedicine physician with the UCLA Center for Behavioral and Addiction Medicine, “Patients on opioids often are surprised that they can get similar, or even greater, pain relief on lower doses of opioids or even off opioids completely. But this often requires a comprehensive approach to provide sufficient medical, psychological and behavioral support while they slowly taper the opioids.”
Physical and occupational therapy, along with psychological approaches, can benefit some people. “In addition to helping with chronic pain, psychological and complementary treatments can help patients to cope better with the effects of chronic pain so that they are more able to function, even with pain, and to have a better quality of life,” Dr. Heinzerling says.