Transcription:
Managing Pain: Alternatives to Opioids

Melanie Cole (Host): The use of opioids has skyrocketed in recent years, and as a result, addiction to them has increased as well. More and more often, people are looking for alternatives to the use of opioids for acute and chronic pain management. My guest today is Dr. Victor Foorsov. He's a physical medicine and pain management specialist in Comprehensive Pain Management Program at Marianjoy Rehabilitation Hospital. Dr. Foorsov, let's start with a little lesson on opioids. What are they and how are they used in pain management?

Dr. Victor Foorsov, MD (Guest): So very good question. So first of all, let's make a distinction between the difference between opioids and opiates. So an opiate is a natural substance derived from opium. So this may include morphine, this may include heroin, this may include codeine as well. An opioid is a synthetic substance that has been made and manufactured. These may include things like oxycodone, hydrocodone, things that you may have heard about such as Percocet, Dilaudid, fentanyl. These are all synthetic substances and referred to as opioids.

Now I'm not an addiction specialist, but generally what the definition of addiction is, is engagement in an activity or use of a substance, and that is compelling, and that also affects one's life in a way that is maladaptive, and in a way that also rewards or causes influence on the brain, namely our dopamine center.

So addiction can take many forms. It can be compulsive gambling, it can be alcohol addiction, and opioid addiction is very similar in that it does reward our- or does influence our reward centers, and again our dopamine centers. Why people have addictive personalities, and why do some people who by chance take these substances, let's say after a surgery, become very influenced, and why others do not, I think this is still an ongoing science, but certainly there's a segment of the population who are more prone to addiction as opposed to other segments of the population who may become exposed to certain substances and they do not form anything that is habit forming.

Host: Doctor, what had been the parameters or the guidelines for prescriptions of opioids? What's different now? Because we're hearing about this epidemic, and we're hearing that there's a new stewardship involved, and that pain management specialists are looking for alternatives. So what is it that you're doing now that is different than what you were doing to manage chronic pain?

Dr. Foorsov: We're really learning- and that's a really good question. We're really learning that the use of opioids in the management of chronic pain- and let's also make a very clear distinction or difference between acute pain and chronic pain. So chronic pain is a disease entity in itself, and that's really important to understand. It's a disease like heart disease, it's a disease like diabetes, and we manage diabetes over the long term. We don't have a cure for it, and in a very similar way, we do not have a cure for chronic pain. Chronic pain is defined as pain lasting for three months or greater, and it could be in the absence of the initial injury. So physiologically, the injury may not be there, but you may still be in pain.

Now acute is pain that's lasted three months or less. Typically let's say acute pain is after an injury. You sprain your ankle, you are in acute pain. Or you had a surgery, you are in acute pain. And we've typically been utilizing opioids to manage acute pain. What the difference has been is that for the past decade, we've been managing chronic pain using opioids. The more and more data now has showed that the effectiveness of chronic opioid utilization for chronic pain in the long term has not demonstrated any significant improvement in quality of life or overall improvement of pain, and as we all know now, what is happening with our society with addiction and the problems with the opioid crisis, I think there's now a lot more pressure to find appropriate alternatives in order to really manage pain in a manner that really helps somebody function, helps somebody's pain as well, without exposing patients to such risk as opioids have done so in the past.

Host: So then let's talk about some of these new approaches, because as you mentioned, acute and chronic pain being different and treatment for them is going to require multiple different approaches. So speak about some of the non-surgical alternatives to opioids for pain management whether we're talking about injection, or acupuncture, or spinal cord stim, or exercise, physical therapy. Kind of go through them for us, Dr. Foorsov, and explain how they work for pain management as opposed to necessarily a prescription for opioids.

Dr. Foorsov: That's a really great question. So I think what pain management should be, or in the view that I have for pain management is, I want to be able to help the patients be able to help themselves. The core for this, and if you look at sort of a hub and spoke kind of way of looking at this, the hub is really physical activity exercise, and all the spokes are used as tools to support this. So first of all, what are appropriate medications? So you have a type of pain. If you have pain coming from a nerve, you should address that type of pain using appropriate medications that are effective for nerve pain. So there are medications called membrane stabilizers such as - you might have heard - Neurontin, or Gabapentin, Lyrica. Those are appropriate types of medications to address nerve pain.

If you have inflammatory pain, you should use medications that address these inflammatory situations. So those are appropriate meds for those kinds of pain. And if you have central pain, meaning pain that you have after a stroke for instance, then there are also appropriate medications that act centrally, in the central nervous system, that have a better effect. So opioids may not be the best choice for those kinds of situations.

The alternatives are- it's not just medications but of course really looking at the person as a whole. So let's look at biomechanics; what are the influencers that may be causing somebody's pain? If they have low back pain, we should look at things such as their posture, look at their leg length, look at how they're- physiologically, how are they doing? Improving diet is really important, right? So if we have a high sugar diet, this is pro-inflammatory. We should work on reducing all those factors.

Now I'm interventional pain management provider, and there are times when appropriate procedures - injections - can really help. Again, these are not permanent solutions. These are temporizing. They're not changing the anatomy that's there. We're using this injection such as things that you may have heard of like an epidural, or SI joint injection, or we may inject certain joints and put steroids in there. These are tools to help the patient be able to do the exercises, be able to improve their function, be able to lose weight. Essentially giving the window of opportunity for the patient to help themselves.

Now there are some techniques that do allow for longer lasting pain relief. There are techniques such as radiofrequency ablation where we can go through the structure, and that may give six months of pain relief. But again, we're not changing the anatomy so we have limitations. I really strongly encourage my patients to really take upon themselves the responsibility of changing their lives, changing their habits, improving their physical function, and using these techniques as a window of opportunity. And that's how I think we should really look at these procedures.

Repeating them indefinitely, I don't think overall we're going to get a lot of success for many patients if we don't also change the core basic dysfunction that is influencing their pain. Now there are other higher level techniques such as spinal cord stimulation which is also becoming or has become a very useful tool for patients with sciatica, patients with low back pain, and the technology with spinal cord stimulation has also been evolving, and we are going through a revolution with spinal cord stimulation with the various types of devices that are usable.

Also on the horizon, I foresee something called peripheral nerve stimulation, where a small wire is introduced and it causes an effect where it blocks the pain signals to certain structures like nerves that go to the shoulders, nerves that are in the extremities, nerves in the spine. They may have great potential for us in the future, and it's an evolving field, and I'm looking forward to really being part of the future of both spinal cord stimulation as it evolves, as well as peripheral nerve stimulation as this field evolves.

Host: Doctor, as we're wrapping up here in a minute, what are some other ways people can help their own pain management? You've mentioned exercise, but speak about some of the alternative therapies that people might look to. And I mean, purpose in life, spirituality, they can all be a part of this whole program of pain management, but people hear about some stem cell, and alternative therapies, and they're not really sure what they should ask, what questions they should ask to help vet those methodologies.

Dr. Foorsov: That's a really great question. I think there's been a lot of confusion about what kind of treatments are appropriate. There are appropriate- there is an emerging science with stem cells. For instance, I've been involved in a study utilizing a certain line of stem cells at Cleveland Clinic for low back pain. And this has been done very methodically. It's a very rigorous study design and it has a lot of science behind it. What I would advise for the consumer at this point in time is to really stick with these invasive procedures that have been where you're introducing something into your body that has been- at least been somewhat vigorously studied, and additionally if they're [Inaudible 00:12:41], then you know that it's been vigorously explored, and you can count on the fact that this has been something that has some merit behind it.

I would just be a little bit wary about potentially exploring avenues where the science is not so strong at this point yet. It may be shown that certain stem cell treatments may be potentially helpful, but the science simply is just not there at this point in time. Really the basics are important, so doing things such as- and you mentioned spirituality. Things like Tai Chi, this is very helpful. Meditation, this is very helpful. You know, aerobic exercise is very helpful as well. It actually forms the core of treatment for conditions like fibromyalgia, and so we should really focus on these types of treatments, and then utilize what we know does help to really enable the patient to take control of their pain. We have to be realistic. With chronic pain, we're managing. We're not necessarily trying to be able to eliminate a person's pain completely. What we're looking to do is help a person improve their pain, improve their ability to do the things that they want to do, and improve their enjoyment of life, and that really is the main goal.

Host: And that is a great place for us to wrap up, Dr. Foorsov. What great information. Thank you so much for coming on, for sharing your expertise, and explaining so very well - you're a very good educator - all of these different alternatives to pain management for people that may want to steer clear of opioids, so thank you again for joining us. You're listening to Northwestern Medicine PodTalk. For more information on the latest advances in medicine, please visit www.NM.org. That's www.NM.org. This is Melanie Cole, thanks so much for listening.