14May17 Alternatives to Opioids
As a society, we are too quick to use opioid pain relievers. They certainly have their place, but in this world where a pill will cure whatever ails you, when a patient complains, too often, the prescriber prescribes opioids. How many prescribers actually suggest alternatives to their patients? How many insist their patients try alternatives BEFORE writing an opioid prescription?
This may be changing as the opioid epidemic grows more out of control. Earlier this year The Department of Health and Mental Hygiene announced that it was instituting new rules for prescribing opioids to Medicaid patients. The American College of Physicians announced new guidelines for treating lower back pain, one of the most common reasons for doctor visits, with therapies such as massage, spinal manipulation or acupuncture, rather than drugs.
Prescribers should consider opioids the LAST resort instead of the first. But for those prescribers who do try to get their patients to agree to try something different, it can be difficult to get them to agree to try alternative treatments. These types of treatments may require repeated visits to a practitioner’s office and can be physically uncomfortable, tedious and expensive; taking a pill is easier. The results are not seen as quickly and patients don’t want to ‘work’ for pain relief. There, of course, is the added problem that some insurance companies don’t cover some of the alternative treatments such as acupuncture.
After some research, I have compiled a list of more common alternative treatments with a brief description of each. I do remember an experience that occurred when I worked for a doctor who was trained in acupuncture. I got a call from one of his patients that had “thrown out his back”, he asked if the doctor could see him for acupuncture. The doctor readily agreed and a short time later the patient hobbled into the office. He could barely walk. The treatment took about 30-45 minutes after which the man came out walking upright and without difficulty. He said he felt like dancing. I may not have believed it if I hadn’t seen it myself. Acupuncture really works. So do acetaminophen and NSAIDs. When I was addicted to opioids, I would never have considered these as true pain relievers. Sure they worked for the occasional mild headache, but for real pain I needed real drugs. I was amazed to discover, after surgery shortly after getting clean from opioids, that acetaminophen was effective for my surgical pain. Again, I would not have believed it if I hadn’t experienced it.
As with any treatment, patients should make sure that the practitioner has appropriate training and experience. But as a medical community, let’s try something new, or not so new. Let’s stop using these addictive and dangerous drugs to treat things that could be managed with less threatening treatments. Let’s just try…
Acetaminophen, the active ingredient in Tylenol, is another common and effective pain reliever. It is recommended as a first-line of treatment by the American College of Rheumatology.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
These are more potent than acetaminophen, but also available in over-the-counter dosage. Higher doses can be taken with a prescription. NSAIDs include anti-inflammatory drugs, such as Motrin and Aleve. The downside to these drugs, for older patients, is risk of organ toxicity, kidney or liver failure and ulcers.
Steroids inhibit injured nerves to provide pain relief. Drawbacks include immune system suppression, gastrointestinal issues and psychiatric effects.
Serotonin and Norepinephrine Reuptake Inhibitors
These anti-depressants are appropriate for treating nerve, muscular and skeletal pain. Anti-depressants can also help people sleep. They offer help without the side effects of opioids.
This treatment uses implanted electrodes to interrupt nerve signals. This does not cure what is causing the pain, but stops the pain signals before they reach the brain. It can be used for back, neck, arm, or leg pain. Trials are currently underway to test their effectiveness on headaches.
Traditionally used to treat epilepsy, anticonvulsants can also relieve neuropathic pain by suppressing pain signals from the brain.
Arthritis, injuries, muscle pain, and headaches are among the kinds of pain treatable with injections. Types include nerve, trigger point, radiofrequency, and epidural injections.
This requires more work from the patient (attending sessions as well as following up at home with recommended exercises) but is often essential to improving physical healing and relieving pain long-term.
Also called spinal manipulative therapy or manual therapy, combines moving and jolting joints, massage, exercise, and physical therapy. It’s designed to relieve pressure on joints, reduce inflammation, and improve nerve function. It’s often used to treat back, neck, shoulder, and headache pain.
Massage, Acupuncture and Chiropractic Care
Some report these methods are just as effective, if not more effective, than medications. Plus, they are safe and free of side effects.
Doctors recommend exercise to all patients, but research has shown that it is especially important for those with chronic pain. Low-impact exercise helps improve mobility and functionality. Studies have shown that chronic back pain, joint pain, arthritis, and fibromyalgia can all be improved with yoga and tai chi.
For most people, the idea of smelling something to make you feel better may sound a bit silly, at best. But aromatherapy has been used for pain management since the time of the ancient Egyptians. Peppermint oil, lavender oil, chamomile oil, and African marigold oil have been used for pain management ever since.
Hypnotherapy is an alternative practice where a licensed hypnotherapist guides your mind to a highly focused mental state.
Natural pain treatments include herbal medicines—plants that are used to treat health problems including pain management. The seeds, berries, roots, bark, leaves, and flowers of plants have been used as medicine long before recorded history. Many modern day pharmacological medicines are based off herbal remedies.
~Capsaicin: Derived from chili peppers, capsaicin has been known to reduce the pain sensation to the central nervous system.
~Ginger: The phytochemicals in ginger have been known to reduce inflammation.
~Turmeric: The active ingredient in turmeric, curcumin, has been known to reduce inflammation and pain.
Medical marijuana is a controversial, non-opioid alternative for pain. More and more states are passing laws allowing medical marijuana use for conditions such as pain, headaches, nausea, seizures, and Crohn’s disease.
In this procedure, which was first used in 1931, a physician uses electric currents to decrease pain signals from a specific nerve.
The practice of acknowledging the present moment and accepting one’s feelings — can be a great benefit to patients with chronic pain. Many patients spend much of their time in pain or worrying about when it will come back, and mindfulness helps them accept their situations and can reduce the intensity of pain
Cognitive Behavioral Therapy
Many people with unrelenting chronic pain can feel hopeless. Cognitive behavioral therapy can help them practice “acceptance theory,” which can lead to changed behaviors and perceptions, and increase a patient’s’ confidence and self-efficacy for managing pain.
Having an exit plan
An article in the Journal of the American Pharmacists Association, Opioid exit plan: A pharmacist’s role in managing acute postoperative pain, found that “[A] hospital pain management team operating a pharmacist-led opioid exit plan (OEP) can be key to guiding the appropriate prescribing practice of opioids and assisting with transitions of care on discharge.” Genord and coauthors see OEP as a tool that has the potential to “expand the role of pharmacists in managing acute pain in postoperative patients.”
Some hospitals are changing the way they address pain during surgical procedures. Patients are administered less addictive pain medication before and during surgery to reduce recovery time and complications. In one example, patients are given three non-addictive painkillers before his surgery to reduce pain and sensation. Then a nerve block is placed in the surgery area during the procedure to more directly target the pain. Other changes include, no longer requiring patients to fast or remain on bed rest for several days after surgery, and giving patients large amounts of IV fluids. The medical community believes these common surgical protocols can cause more harm than once thought.