Better Ways to Trump Pain, Despite Opioid Disdain

If you don’t think pain and its treatment is an issue, then look no further than many of the patients and celebrities (e.g. Heath Ledger, Philip Seymour Hoffman, Andy Irons, Prince Rogers Nelson) who have died from addressing their pain with opioids. From 1999 to 2014, more than 165,000 people have died from opioid overdose, which in many instances is a combination of opioids, benzodiazepines, and/or alcohol.

 Unintentional overdoses are now the leading cause of accidental death that has now surpassed motor vehicle accidents.

And although there is a huge surge of illegal production and distribution of opioids in the form of carfentanil, heroin, and others, there is no doubt that a massive influx of opioids into medicine cabinets are due to physicians writing the prescriptions. (See DEA Warning about carfentanil posted on 9/23/2016 at https://www.dea.gov/divisions/hq/2016/hq092216.shtml)

Opioids not only can lead to death; but, they can generate misuse, abuse, and addiction in certain individuals. This struggle is highlighted with the recent release of Macklemore’s Drug Dealer video:

One in four people who receive opioids battle with addiction and there is a lack of resources to help those suffering from it. Nearly 2 million Americans were dependent on opioids in 2014. Every day over 1,000 people are treated in the emergency room for misusing prescription opioids. No matter if opioids help some people cope with non-cancer pain, the risk of life itself and the quality of that life will always remain, regardless of why opioids are taken.

There is a time and a place for opioids, predominantly for acute pain or trauma including surgery and also for cancer. But here is the bigger and more important question:

Why do physicians continue to write so many opioid prescriptions for non-cancer pain despite the risk?

The reasons are numerous and include fragmented and inadequate pain education. The savviest of patients know that opioids do not fix the problem and that they come with potential adverse effects. Yet, the focus of conversation in society is on the acute management of reversing an opioid overdose with naloxone or non-medical entities trying to dictate or regulate the opioid prescribers’ practice of medicine.

Focusing on the dark side of opioid use can seem like a worthy venture to rally behind, but it becomes smoke and mirrors without addressing the underbelly of our nation—pain and suffering.

Opioid over-fixation by society can be the proverbial dog chasing its tail.
Poor pain management is not a lack of acute overdose treatment nor is it a lack of government regulation of the practice of medicine; it’s a lack of deeper understanding of pain and its biological, psychological, and sociological underpinnings at all levels. For if we could more accurately diagnose pain, then we would not be just treating symptoms. Fundamentally speaking, if you focus on symptoms as the problem, then the drive to truly understand the etiology or root cause is hindered.

The perplexing phenomenon of pain is further complicated by the strong innate human drive to avoid pain definitively and quickly. This puts humans in a vulnerable position—one in which pharmaceutical industries have capitalized on and also physicians who have sold procedures and surgeries to patients in the name of “fixing” pain. Patients are at the mercy of the direction they are taken by the medical system; if society focuses on symptoms, then the patients' deeply embedded tendency for a quick fix will just be reinforced and substantiated.

For example, going to a primary care physician who has poor pain education and then referred to a surgeon with the diagnosis of degenerative disc disease (but no emergency issues) will surely not bode well for conservative care unless the surgeon is a proponent of its benefits. There are countless patients who are receiving pain injections chronically as their sole approach to pain management without any understanding of self-care or other options; in fact, most fear pain and avoid activity. This is one of many examples of a setup for disaster. It is society’s ethical obligation to enable patient/provider education and availability and access to the best options that all realms of medicine have to offer. There needs to be a revolution of society’s expectations of pain management (not just a pill, injection, or surgery) and the constitution of more holistic, interdisciplinary pain practices.

So, what constitutes better pain management?

*First, rule out true emergencies or urgencies, such as severe neurological compromise, cancer, infection, etc. with a primary care physician or medical professional.

*Accurate diagnosis should be paramount, as poorly diagnosed or misdiagnosed issues will likely be ignored or treated improperly. Chronic pain can result from poorly treated acute pain.

Understand pain is a brain phenomenon that is impacted by the periphery and the central nervous system. Pain is an alarm system that something is not in balance or not quite right, but not necessarily life-threatening.

• Neuropathic pain that arises from damage or disease of the nerves (e.g. complex regional pain syndrome, aka CRPS) can be more challenging at times than nociceptive pain but they are both experienced in the brain.
• Either pain experience in the brain can receive input from the periphery, but anxiety, smoking, lack of sleep, inflammatory foods, depression, stress, and inactivity have the potential to increase pain as well.

Self-care follows the understanding that certain behavior patterns can impact pain negatively or positively.

• Quitting smoking, improving sleep, eating less processed foods, less stress, decreasing excess weight, and a less sedentary life can help pain as well.
• Moving well with variety can do wonders for some people. Basic, gentle, and fuller range of motion on a daily basis or other practices such as yoga can help decrease pain.
• It does not take advanced technology to address the basics. Unlike medical interventions, which are rare and infrequent, patients spend most of their time with themselves; which makes self-care an essential component to truly effect change in a sustainable way.

Avoid silo medicine, cookie-cutter medicine, or de-personalized medicine.

• Only one style of treatment discussed or offered may not give best options.
• Not listening well to the patient’s story could miss something important while at the same time make the patient feel as if they have not been heard.
• Lack of education or skills discussed with the patient is not helpful nor empowering.

Biomechanical evaluation is not taught to most MD physicians in their training:

• When self-care is not achieving pain relief, then deciphering root cause or putting pain into a sub-group classification [not just a symptom-oriented diagnosis, e.g. failed back surgery syndrome, nonspecific back pain, etc.] can be more helpful.
• Most chronic pain is musculoskeletal and not inflammatory, and thus should be screened and assessed by a biomechanical expert. Without proper diagnosis, pain can become chronic and more complex.
• There are multiple frameworks of addressing biomechanics, but the first one below, the McKenzie Method (aka MDT or Mechanical Diagnosis and Treatment), is mounting great evidence. In fact, it is even changing several orthopedic surgeons’ approaches (See Mechanical Care Forum Podcasts #140-142 here: http://bit.ly/jasonwardpt )

1. Physical therapists, especially with McKenzie Method training [MDT designation], have a highly specialized but patient-centric, educational approach. Instead of focusing on a patho-anatomical diagnosis (e.g. herniated disc) that is common for many physicians and patients to fixate on, it assesses the mechanical diagnosis using pain as a guide when assessing the patient’s directional preference. Effective treatment is based on those evaluations. In studies, nearly half of those anticipating surgery for disc-related pain have resolution of their pain without need for surgery when treated by a well-trained MDT therapist. (See Resources below)
2. Osteopathic Physicians (D.O. - Doctors of Osteopathic Medicine) who specialize in Osteopathic Manipulative Medicine/Treatment (OMM/OMT) use a variety of techniques to treat or improve pain. Education and techniques can vary greatly but can incorporate approaches that look similar to physical therapists, chiropractors, and/or massage therapists. (Four Tenets of Osteopathic Philosophy)
3. Chiropractors, especially those who use Selective Functional Movement Assessment (SFMA) training. SFMA is a movement-based diagnostic system, designed to clinically assess 7 fundamental movement patterns in those with known musculoskeletal pain. It is intended to break down dysfunctional patterns to decipher if the root cause is a mobility or stability/motor control problem.

As a reminder, there can be variability of perspectives, techniques, and practices by any practitioner even within a specialized profession. Second opinions within or across specialties (beyond those mentioned above) may offer other options. Any of the above approaches should be accompanied by educating patients and offering ways or skills for patients to help themselves.

Loose connective tissue (aka fascia) is woven within biomechanics, and tends to tighten with age (elasticity decreases) with the potential for pain. There are multiple ways to address this tissue while also keeping an eye on the biomechanics that affect it. Improving flexibility can have profound effects, including enhanced function and performance of the musculoskeletal system; one of the benefits of practices such as yoga. There are professionals such as those below who can assist with improving fascia, whether gently or more aggressively.

• Massage therapists
• Physical therapists
• Osteopathic physicians (D.O. physicians)
• Acupuncture, amongst other proposed effects, has been shown to cause small stretches on the connective tissue’s cells called fibroblasts, leading to signaling to other nearby cells to elongate as well.

It is important to remember that each “system” of the body does not work in isolation from one another. Thus, the above methods, including acupuncture, tend to impact other systems (e.g. nervous system, immune system, etc.) directly or indirectly to varying degrees. Benefits may extend beyond the initially perceived benefits.

Managing the brain when pain persists despite patient or professionally-aided efforts is just as important as defining the nociceptive input (pain that arises from stimulation of nerve cells) to the brain. There are effective ways to help patients cope with or decrease the brain’s pain experience. Some of the techniques that therapists, psychologists, etc. can use or teach are the following:

• Cognitive behavioral therapy (CBT)
• Acceptance and Commitment Therapy (ACT)
• Mindfulness/Meditation

To have all of the above and more under one roof for patients would be the ultimate destination for patients to learn and heal, but more work needs to be done to see this become a reality in all corners of the country. Then maybe this country will realize that opioids are truly a last resort for most non-cancer pain.

Pain is a journey in many cases, with a need to address a variety of issues sometimes requiring multiple opinions. As a complex phenomenon, it takes patience from both sides—the patients and those who treat them. Quick fixes with pills will not help instill the behavioral changes or skills needed by so many who are suffering. The real focus should be on creating education, more precision in diagnosis with more strategic treatments, support, and alternatives for those in need—and they need to be available and affordable. It really will take a village for a landslide victory to trump pain!

Resources not mentioned above:

https://www.cdc.gov/drugoverdose/data/overdose.html

https://www.dea.gov/divisions/hq/2016/hq092216.shtml

Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2014.

Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction 2010;105:1776–82. http://dx.doi. org/10.1111/j.1360-0443.2010.03052.x

Substance Abuse and Mental Health Services Administration. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. The DAWN Report. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2013. Available from URL: http://www.samhsa.gov/data/2k13/DAWN127/sr127-DAWN-highlights.htm

J.R. Kopp et al, “The Use of Lumbar Extension in the Evaluation and Treatment of Patients with Acute Herniated Nucleus Pulposus: A Preliminary Report,” Clinical Orthopaedics and Related Research, (1986):211-218.

Ron Donelson et al, "Influence of Directional Preference on Two Clinical Dichotomies: Acute Versus Chronic Pain and Axial Low Back Pain Versus Sciatica," PMR, (Sept 2012);4(9):667-81. doi: 10.1016/j.pmrj.2012.04.013

Claus Rasmussen et al, “Rates of Lumbar Disc Surgery Before and After Implementation of Multidisciplinary Nonsurgical Spine Clinics,” SPINE Volume 30, Number 21 (2005): 2469–2473.

John C. Licciardone et al, “Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: A Randomized Controlled Trial,” Ann Fam Med 11, no. 2 (2013):122-9. doi:10.1370/afm.1468.211

John C. Licciardone, Angela K. Brimhall, and Linda N. King, “Osteopathic Manipulative Treatment for Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” BMC Musculoskeletal Disorders 6, no. 43 (2005): 12 pages. doi:10.1186/1471-2474-6-43

http://www.functionalmovement.com/certification/sfma

Helene M. Langevin et al, “Dynamic Fibroblast Cytoskeletal Response to Subcutaneous Tissue Stretch Ex Vivo and In Vivo,” American J Physiology - Cell Physiology 288 (2005): C747–56. doi:10.1152/ajpcell.00420.2004.120

Helene M. Langevin et al, “Ultrasound Evidence of Altered Lumbar Connective Tissue Structure in Human Subjects with Chronic Low Back Pain,” BMC Musculoskeletal Disorders 151 (2009): published online. doi:10.1186/1471-2474-10-151.121

Helene M. Langevin et al, “Reduced Thoracolumbar Fascia Shear Strain in Human Chronic Low Back Pain,” BMC Musculoskeletal Disorders 203 (2011): published online. doi:10.1186/1471-2474-12-203.122