As the opioid epidemic in the United States continues unabated, doctors in many specialties are trying new ways to treat acute and chronic pain.
The opioid epidemic in the United States continues to grow, fueled in part by the overprescribing of opioid pain medications.
In 2016, opioids were involved in 42,249 deaths, according to the Centers for Disease Control and Prevention. Forty percent of all opioid overdose deaths involved a prescription opioid.
Hoping to slow the epidemic, doctors across the country are looking for ways to reduce the use of opioids to treat pain, both acute and chronic.
In Colorado, a pilot program at 10 emergency departments reduced opioid use among patients by 36 percent, easily besting the studyâ€™s goal of a 15 percent reduction.
Instead of using opioids such as oxycodone, hydrocodone, or fentanyl, emergency room doctors opted for safer and less addictive alternatives â€” such as acetaminophen, ibuprofen, lidocaine, and ketamine.
They also used new procedures, such as a non-opioid patch for pain and targeted injections of non-opioid pain medications.
Other medical specialties are taking action as well.
Hereâ€™s what four doctors had to say about how their profession is reducing opioid prescriptions for patients.
Dr. Nancy Nielsen, senior associate dean for health policy at Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo in New York
Nielsen said that primary care doctors are â€œtrying to change how we practice, so we donâ€™t use opioids as a first-line treatment or even for a while, because there are other ways to approach pain.â€
She said physicians should still â€œtry to ameliorate suffering, but maybe pain- free is not always the goal. Getting people back to their best functional status is really the goal.â€
This shift requires doctors to educate patients about what to expect in terms of pain.
â€œFollowing surgery or an injury, you may not be pain-free,â€ Nielsen told ishonest. â€œYouâ€™re not supposed to be suffering terribly, but you may not be pain-free.â€
Primary care doctors now use non-opioid approaches more often â€” such as anti- inflammatories, muscle relaxants, stretching exercises, physical therapy, and chiropractic or massage therapy.
â€œA lot of these are more nontraditional approaches,â€ said Nielsen. â€œThe problem is that insurers often do not pay for them.â€
Chronic pain medicine
Dr. Kim Mauer, associate professor of anesthesiology and perioperative medicine at the Oregon Health & Science University School of Medicine (OHSU)
Mauer said pain physicians may still use opioids to treat acute pain, such as after surgery or an injury.
But chronic pain requires a different approach. In these cases, opioids either donâ€™t help or make matters worse.
â€œAfter three months â€” which is our definition now of chronic pain â€” we move away from using medications and more into lifestyle changes, health and wellness, and overall life balance,â€ Mauer told ishonest.
This includes focusing less on a personâ€™s pain and more on work-life balance and what they enjoy.
â€œThese can distract from your pain and make you stronger and healthier so your pain is a smaller component of the overall stress in your life,â€ said Mauer.
To support patients, the OHSU Comprehensive Pain Center has incorporated alternative and complementary therapies into their practices.
These include acupuncture, massage therapy, Rolfing and reiki, nutrition and naturopathy, chiropractic, cognitive behavioral therapy, yoga, and mindfulness.
Thereâ€™s limited research, however, on how effective these are for pain. So researchers at OHSU are trying to fill in the blanks.
â€œWeâ€™re starting some studies that look at whether there are alternative therapies that work better for certain chronic pain conditions,â€ said Mauer.
Dr. Jennifer Waljee, MPH, co-director of the Michigan Opioid Prescribing Engagement Network (OPEN) and associate professor of plastic surgery at the University of Michigan School of Medicine
One way to reduce opioid prescriptions is to figure out exactly how many pills patients need after surgery.
That isnâ€™t always an easy task.
â€œWe want to make sure that our patientsâ€™ pain is well-controlled and that they have a comfortable recovery,â€ Waljee told ishonest. â€œHowever, it has historically been challenging to understand exactly the right amount of opioids that are necessary to prescribe after surgical procedures.â€
She said that more research is showing how much opioids patients consume on average after surgery. Surgeons can also fine-tune their prescribing by talking to patients.
â€œI think taking very simple measures â€” such as asking patients about their preferences for pain control after surgery and their prior experiences with surgery â€” can reduce the prescribing of opioids,â€ said Waljee.
On top of this, surgeons may offer patients non-opioid approaches to pain.
â€œResilience exercises, mindfulness, and breathing can be very helpful for pain control after surgery, in addition to over-the-counter options such as Tylenol and NSAIDs [nonsteroidal anti-inflammatory drugs],â€ Waljee said.
Physical medicine and rehabilitation
Dr. Andrew I. Gitkind, medical director of the Montefiore Spine Group and associate director of the Multidisciplinary Pain Program at Montefiore Health System
â€œWe utilize a lot of physical therapy or other therapy modalities to try to help people manage their symptoms and pain,â€ Gitkind told ishonest. â€œI say â€˜manageâ€™ because often what weâ€™re teaching people to do is take control of their pain to some degree, which gives them a sense of independence.â€
For back-related or spine-related pain, physical medicine and rehabilitation doctors often use â€œfluoroscopically guided injections or other types of procedures to try to help control pain. This reduces the need for chronic use of opioid medication.â€
Other non-opioid medications can also be effective as a first-line treatment, including acetaminophen, NSAIDs, and drugs tailored for neuropathic, or nerve- related, pain.
Gitkind said that itâ€™s also important to set realistic initial expectations for patients, especially if theyâ€™ve been dealing with pain for years.
The focus is to make them feel better, rather than curing them of their pain.
â€œA lot of that has to do with behavioral therapy and cognitive behavioral therapy, and how you think of your pain,â€ he said. â€œRather than what canâ€™t you do, what can you still do?â€