Author
The International Association for the Study of Pain (IASP) defines chronic pain as “pain that persists beyond the normal time of healing, usually more than three months.”[1] Over 25 percent of the US population has chronic pain of various degrees, and older individuals have a higher prevalence of chronic pain.[2],[3] Roughly 20 percent of outpatient complaints in clinics are pain related, and more than half of patients who see their primary care provider do so for pain.[4] Overall, the costs associated with pain management are higher than the combined expenses related to diabetes, cardiac disease, and cancer.[5] Annual estimates range from $560 to $650 billion.[6] In this blog, we will discuss the alternatives to opioids for chronic pain control.
Chronic pain can be categorized in various ways. Categories can be based on the physical location of the pain, its cause(s), or the primary anatomical system affected. The latest version of the International Classification of Diseases (ICD) offers seven major categories of chronic pain: primary, cancer, posttraumatic and postsurgical, neuropathic, headache and orofacial, visceral, and musculoskeletal.[7] Prolonged illnesses, injuries, and diseases can cause chronic pain. Sometimes, multiple causes can contribute to and intensify chronic pain. Individuals can experience chronic pain as “aching, burning, shooting, squeezing, stiffness, stinging, [or] throbbing.”[8]
The US Department of Health and Human Services points to a lack of emphasis on pain management in medical education as one cause of a shortage of pain management professionals. As of 2019, the US had only 5,871 active pain medicine and pain management physicians—about one per every 56,453 people.[9] A greater number of specialized pain management clinicians are needed to meet the demands of patients with chronic pain. The American Board of Medicine describes the disequilibrium in the pain management labor market and its negative consequences as a “shortage of pain medicine specialists [that] impedes the efforts to provide efficient, cost-effective health care delivery models for treating the vast population of patients with chronic pain.
The lack of research on the most effective clinical pain treatment protocols for specific medical conditions exacerbates the problem.”[10] Lack of research to develop clinical best practices also contributes to the scarcity of well-trained pain management professionals.[11] In rural areas, the shortage is often worse. Besides the shortage of adequately trained physicians, patients “affected by drug addiction and pain management cannot find help as local pharmacies and nearby hospitals have been closing.”[12]
Absent well-qualified pain management professionals, patients seek treatment for their chronic pain from their primary care physicians (PCPs). Unaware of all the options for treating chronic pain, PCPs, surgeons, and other specialists often overprescribe opioids – too many and for too long – which can lead to misuse among patients.[13],[14]
The 2019 federal Pain Management Best Practices Inter-Agency Task Force (“the Task Force”) addressed the treatment of pain during the current opioid crisis. Its recommendations included the use of interventional pain management to reduce the use of oral prescriptions.[15] Implementing the recommendations of the Task Force, some states have enacted statutes and regulations to address opioid abuse among people with chronic pain. These programs are intended to curtail the number of opioid prescriptions by requiring pharmacists to use drug-monitoring systems to track prescriptions of controlled substances by patients and by providers. Some systems also generate prescriber reports that signal the potential risk to patients of addiction, based on a physician’s prescription patterns.
The Task Force also recommended that pain management professionals understand the full range of pharmacological and non-pharmacological options and their respective benefits and risks for different patient populations. The Task Force report emphasizes a multimodal approach that combines various strategies to provide comprehensive and personalized pain management. The recommendations cover four main treatment modalities:
- Physical and occupational therapists can substitute restorative therapies to achieve better physical outcomes or keep physical functionality. Therapeutic massage techniques can reduce muscle tension, improve circulation, and promote relaxation. Cold and heat can only treat symptoms and can provide temporary relief for pain.
- Interventional procedures are minimally invasive and are usually part of a broader pain treatment program. Nerve block injections interrupt pain signals to provide temporary relief. TENS units or spinal cord stimulators (SCS) deliver mild impulses to decrease pain perception. Radio frequency ablation (RFA) interrupts pain signals by creating a small cut on nerves.
- Complementary and integrative healthcare uses a wide variety of techniques to manage pain. Mindfulness-based stress reduction (MBSR) uses meditation, body awareness, and yoga to reduce pain and stress. Yoga and Tai Chi often involve small, gentle movements, stretching, and breathing techniques to lessen pain. Herbal and dietary supplements, like curcumin, may reduce inflammation-related pain. Acupuncture involves inserting thin needles at specific points on the body to lessen pain.
- Behavioral health techniques can influence patients’ experience of and reaction to pain. Acceptance and commitment therapy (ACT) helps individuals accept their pain while taking actions to mitigate suffering. Biofeedback helps individuals gain awareness and control over physiological functions, such as muscle tension, which can influence the perception of pain.
The effectiveness of these non-opioid alternatives can vary depending on individual circumstances and the specific nature of the chronic pain condition.
Companies offering nonresidential drug abuse treatment programs should know pain management alternatives to counsel their patients on managing chronic pain as part of managing addiction.
[1] “Definitions of Chronic Pain Syndromes,” IASP, https://www.iasp-pain.org/advocacy/definitions-of-chronic-pain-syndromes.
[2] Richard L. Nahin, “Estimates of Pain Prevalence and Severity in Adults: United States, 2012,” The Journal of Pain 16, no. 8 (2015): 769–780.
[3] Una E. Makris, Robert C. Abrams, Barry Gurland, and M. Carrington Reid, “Management of Persistent Pain in the Older Patient: A Clinical Review,” JAMA 312, no. 8 (2014): 825–837.
[4] Daniel P. Alford, Erin E. Krebs, Ian A. Chen, Christina Nicolaidis, Matthew J. Bair, and Jane Liebschutz, “Update in Pain Medicine,” Journal of General Internal Medicine 25 (2010): 1222–1226.
[5] Philip A. Pizzo and Noreen M. Clark, “Alleviating Suffering 101—Pain Relief in the United States,” New England Journal of Medicine 366, no. 3 (2012): 197–199.
[6] Darrell J. Gaskin, and Patrick Richard, “The Economic Costs of Pain in the United States,” The journal of Pain 13, no. 8 (2012): 715–724.
[7] Rolf-Detlef Treede, Winfried Rief, Antonia Barke, Qasim Aziz, Michael I. Bennett, Rafael Benoliel, Milton Cohen, et al., “A Classification of Chronic pain for ICD-11,” Pain 156, no. 6 (2015): 1003.
[8] “Chronic Pain,” https://my.clevelandclinic.org/health/diseases/4798-chronic-pain#symptoms-and-causes, accessed February 8, 2023.
[9] “Active Physicians with a US Doctor of Medicine (US MD) Degree by Specialty,” Association of American Medical Colleges, https://www.aamc.org/about-us/mission-areas/health-care/workforce-studies/interactive-data/number-people-active-physician-specialty-2019, accessed February 8, 2023.
[10] “Why the US Should Develop a Primary Medical Specialty in Pain Medicine,” American Board of Pain Medicine, http://www.abpm.org/uploads/files/talking%20points%20-%20federal%20approach%20needed%20final.pdf, accessed February 7, 2023.
[11] Centers for Medicare and Medicaid Services, “Summary of Review and Recommendations for the Medicare and Medicaid Programs to Prevent Opioid Addictions and Enhance Access to Medication-Assisted Treatment,” https://www.cms.gov/files/document/report-congress-behavorial-health-strategy.pdf, accessed February 7, 2023.
[12] Emil Chuck, “Application Advice for Future Rural Health Professionals,” The Student Doctor Network, https://www.studentdoctor.net/2022/11/17/application-advice-for-future-rural-health-professionals, accessed February 7, 2023.
[13] Bradley M. Gray, Jonathan L. Vandergrift, Weng Weifeng, Rebecca S. Lipner, and Michael L. Barnett, “Clinical Knowledge and Trends in Physicians’ Prescribing of Opioids for New Onset Back Pain, 2009–2017,” JAMA Network Open 4, no. 7 (2021): e2115328–e2115328.
[14] Wilson M. Compton, Maureen Boyle, and Eric Wargo, “Prescription Opioid Abuse: Problems and Responses,” Preventive Medicine 80 (2015): 5–9.
[15] US Department of Health and Human Services, “Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations,” May 2019, retrieved from US Department of Health and Human Services website: https://www.hhs.gov/opioids/prevention/pain-management-options/index.html.