Editor's Memo: Real Progress—Non-Opioid Advances in Pain Management
By listening to the media these days, one would think that opioid abuse and epidural steroid injection complications were the only thing happening in pain management.
The reality of contemporary pain treatment and the advances made since the seminal enactment of pain as the Fifth Vital Sign in 2001 are truly remarkable. What is often overlooked is that some of the most important advances in pain management have been made in areas that do not include either opioids or epidural steroid injections. The non-opioid medical advances have greatly impacted opioid use for the vast majority of new pain patients. For example, the adjuvant use of non-opioids has made it possible to reduce the dosages of opioids in the vast majority of cases. The only ultra-high dose opioid patients that I see started therapy years ago before we had many alternative measures and contemporary knowledge about opioid selection. Put another way, more people may be taking opioids but the opioid usage, per patient, is dramatically down.
The non-opioid, non-epidural steroid measures are numerous and difficult to rank in importance. Consequently, I’ll mention some that have greatly impressed me.
Chronic pain patients today routinely are being given trials of gabapentin (Neurontin, Gralise, Horizant, others), pregabalin (Lyrica), or duloxetine (Cymbalta, others) to treat neuropathic pain, as well as the next generation of anti-inflammatory agents, particularly celecoxib (Celebrex) and diclofenac, prior to advancing to opioids. The serotonin–norepinephrine reuptake inhibitor duloxetine now is among the most frequently prescribed drugs in the world. It joins a long-list of “old-time” antidepressants that still are useful in selected pain patients. Stimulants and muscle relaxants are sliding into the armamentarium, and top-notch pain practitioners are finding that stimulants can have an opioid-sparing effect. Researchers also are investigating some innovative pharmacologic approaches that appear promising and are beginning to be used outside the university setting. Here I count ketamine (perioperatively and for chronic neuropathic pain), low-dose naltrexone, minocycline (inhibits glial cell activation), and the neurohormones, including human chorionic gonadotropin, oxytocin, and progesterone.
Until recently, no one had ever considered using a patch containing lidocaine (Lidoderm, others) or a topical gel containing the non-steroidal anti-inflammatory drug diclofenac (Voltaren, Solaraze, others). Now topical agents, including patches, creams, and gels, are commonplace in pain practice. The ingenuity and innovation of our compounding pharmacists are bringing us non-oral treatments with such topical compounds as gabapentin, clonidine, ketamine, carisoprodol, and morphine.
Homeopathy and Prolotherapy
These measures require a little training, but the results are worth it. Commercial homeopathic products are available for such conditions as trauma (Traumeel), pain, spasticity, or inflammation.1 Prolotherapy works by causing a temporary, low-grade inflammation at the injection site, which activates fibroblasts; these fibroblasts, in turn, synthesize precursors that mature into collagen, reinforcing connective tissue. Platelet rich plasma (PRP) therapy, like prolotherapy, is a method of injection designed to stimulate healing. Platelet rich plasma is defined as “autologous blood with concentrations of platelets above baseline levels, which contains at least seven growth factors.”2 The word “cure” even creeps into one’s vocabulary when these new approaches are used by an experienced clinician.
A few years ago, the only therapy in this class was transcutaneous electrical nerve stimulation (TENS). We now know that acupuncture, magnets, and copper all manipulate the body’s electromagnetic bioenergy in one way or another. TENS, which works via an electric current, has been joined by a plethora of electric devices that use an innovative mix of currents, including microcurrents. There now are a variety of electromagnetic devices that deliver energy (lasers, infrared, and radiofrequency) that is 50% magnetic and 50% electronic.3 Lasers can treat and even cure all kinds of painful conditions. Radiofrequency energy is great for ablation procedures, and low-frequency devices are available for outpatient use over pain sites that cover a wide area including wounds, burns, and stumps. At-home devices are available to deliver electric currents, as well as laser, infrared, radiowave, and ultrasound energy.
To me the most important scientific breakthrough of recent years is the understanding of centralized pain and its impact on the endocrine and autoimmune nervous system. We now can have a real go at managing the intractable pain states of such central conditions as traumatic brain injury, fibromyalgia, strokes, chronic pain, and complex regional pain syndrome (CRPS).
Mirror therapy and virtual reality are 2 noninvasive and inexpensive treatments that have been amazingly effective at the management of phantom limb pain.4 In an article in PPM, Jack Tsao, MD, described how mirror therapy works. “In this treatment, patients view the reflection of their intact limb moving in a mirror placed parasagitally between the arms or legs. Patients simultaneously move the phantom limb in a manner similar to what they are observing. After 4 weeks of treatment, 100% of patients in the mirror therapy group reported a decrease in pain.”4
Many, many dedicated humanitarian scientists and clinicians have brought us the above measures in a very short time period. In addition to those finding treatments directed at the physical cause of pain, an equal number of researchers have made great strides in understand pain’s emotional toll. We now understand that pre-existing trauma (childhood abuse, injuries, psychological trauma, etc.) has a great impact on a person’s perception of pain. This is why behavioral health interventions, such as Somatic Experiencing and cognitive-behavioral therapy, are part of the multimodal interventions that can be of great help in the treatment of complicated pain syndromes. Also, because there’s a heightened recognition of the effect of anxiety and depression on increasing pain, most chronic pain patients are being treated with antidepressants and/or anti-anxiety medications. And I haven’t even mentioned the improved techniques and teachings related to paraspinal interventions, diet, nutrition, and exercise.
Next time you hear pain treatment being bad-mouthed, just recall the advances we’ve made and the human suffering we’ve reduced. Thanks to all who have made this movement possible. Tell it like it really is!!