Non-opioid pain treatment
Using “rational polypharmacy” to control pain with opioid alternatives
by Jonathan Clapp, MD, Board Certified, Physical Medicine and Rehabilitation, and American Board of Pain Medicine
Preliminary data indicate that drug overdose deaths increased 19 percent from 2015 to 2016 despite increased regulatory control and awareness surrounding the opioid epidemic in the United States. The need for improved education is paramount in limiting potentially dangerous opioids while providing adequate pain relief for the millions of people who struggle to meet vocational and family responsibilities because of their pain. Per population, the rate of drug overdose deaths are almost 2.5 times higher than that of our neighbors to the north in Canada. A contributor is almost surely the difference in hours of standardized pain training in medical schools between the U.S. and Canada (9 hours vs. 19.5 hours on average). The purpose of this article is to outline the utility and importance of non-opioid pain management, otherwise known as “rational polypharmacy.”
Getting the right diagnosis
A correct diagnosis is paramount in any medical condition before one can determine treatment. Accepting a diagnosis from another provider can be misleading and not in the patient’s best interest. An appropriate and detailed history, physical exam and review of any old records, including diagnostic tests or imaging, is paramount on the first visit. Characteristics of pain are also useful in determining the type of pain, which are treated very differently. Nociceptive pain is involved in inflammation, post-surgical, post-physical trauma, etc. It is typically any of the following: sharp, stabbing, dull, achy, etc. Neuropathic pain is typically burning in nature and can have a pins and needles component with shooting and can be in a nerve root, peripheral nerve or (in the case of peripheral neuropathy) a stocking-glove distribution. Central pain is more elusive and can involve large parts of the body. The muscle pains in fibromyalgia are an example, but can be burning, dull and achy as well.
The mantra for treating biomechanical pain is: If you have a structural or mechanical problem, it needs to be addressed structurally or mechanically. This is often a life-long commitment. For example, for low back pain, focus on muscle groups affecting spine that provide better mechanical support (multifidi, transversus abdominis), abdomen, pelvis, thighs, etc. Focus on proper alignment and distribution of forces across the back, such as limb length discrepancies, flat feet, scoliosis and poor posture.
In the last few years, literature has been able to quantify the impact of depression, anxiety and PTSD on pain. For example, a patient with depression or anxiety is two to five times more likely to be on chronic opioids at six months than a patient without, despite the same orthopedic surgical procedure. Catastrophizing (defined as an irrational fear of post-op pain and/or disability) is seven times more powerful than any other predictor in predicting the transition from acute to chronic pain, or being on opioids six months after a procedure. The importance of psychology and perception are huge factors that need to be addressed to best treat pain.
The most accepted psychological modality for treating pain is cognitive behavior modification (CBT) that teaches self-coping statements and problem-solving cognitions in attempts to alter one’s perception of their chronic disease. This can include strategies of imaginative inattention, imaginative transformation of pain, focused attention and somatization in a dissociation manner. The “operant” approach of CBT reinforces good behavior and ignores adverse pain behavior. Exercises should be done at a level to avoid “punishment” for activity, reinforce the positive and reward the patient for achieving goals. Biofeedback teaches muscle relaxation and self-regulation of pain. Other treatments include imagery, hypnosis, meditation and diaphragmatic breathing. Literature shows positive effects in chronic low back pain, fibromyalgia, headache and temporomandibular disorders.
Regarding pharmacology, there is strong evidence supporting the use of non-opioids for pain and some have been quantified as to how many morphine equivalents each can reduce over 24 hours. For example: 1000 mg of IV acetaminophen every four hours results in 6-9 mg less morphine consumption in 24 hours. Ibuprofen 400 mg daily, celecoxib 200-400mg daily and diclofenac 30-60mg per day all resulted in 10.2 mg less morphine consumption. Gabapentin 300-1,200 mg per day also decreased 24-hour morphine consumption by 13-32 mg in 24 hrs. Pregabalin had a dose dependent reduction in morphine (i.e. less than 300 mg/d and greater than 300 mg/d equaled 8.8 mg and 13.4 mg less morphine in 24 hours, respectively.
Nutrition also plays a role in pain management. Vitamins D, B12, B6 and essential fatty acid deficiencies can cause pain. Excess Omega-6 fatty acids without appropriate balance with Omega-3 fatty acids results in inflammatory mediators that are more reactive. Pro-inflammatory foods include foods high in Omega-6 fatty acids, such as red meat, vegetable oil, dairy and tomatoes to name a few.
Supplements can also be relatively safe and effective. The NIH has developed a website that is updated frequently and is a great resource: (https://nccih.nih.gov/health/herbsataglance.htm). For example, s-adenosylmethionine (SAMe) is shown to be as effective as celecoxib in knee osteoarthritis after two months of treatment and as effective as tricyclic antidepressants in treatment of depression. Omega-3 supplementation at 2.7g per day of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) improves pain in rheumatoid arthritis, osteoarthritis and irritable bowel syndrome after three months (recommend at least twice a day dosing). Turmeric, bromelain and ginger up to 4 grams/day in divided doses are also shown to be effective. And for neuropathic pain, alpha-lipoic acid up to 600mg/day in divided doses has shown benefits in (diabetic) peripheral neuropathy.
The challenges remain for us to limit opioids while still treating pain and maximizing function for our patients with pain. Advances need to be made in standardized medical education and development of new non-opioid pain medications. It is important to use what we already have and understand how these can benefit our patients.
1. The average time spent on pain education in U.S. medical schools is:
a. 3 hours
b. 6-9 hours
c. 20 hours
d. 30 hours
2. Which of the following is TRUE?
a. Accepting a diagnosis from a specialist should be accepted even if the patient is not getting better.
b. “Rational polypharmacy” is considered better treatment for patients suffering with pain than one or two opioids alone.
c. Nociceptive pain is characterized by burning, electric, pins and needles, and shooting pains.
d. A structural or mechanical problem should be managed with injections or medications only.
3. Based on current literature, which of the following is NOT considered an appropriate treatment for chronic pain?
a. Cognitive behavioral modification
b. Opioid treatment greater than 500mg morphine equivalents per day
c. Omega-3 supplementation
d. Treating with optimal function being the primary goal
4. Which of the following has NOT been shown to decrease total daily opioid consumption?
5. TRUE or FALSE: A patient with depression or anxiety is two to five times more likely to be on chronic opioids at six months than a patient without, despite the same orthopedic surgical procedure.
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