America’s growing epidemic has guided policymakers and providers toward treatments such as nerve blocks, medical marijuana and even acupuncture.
Despite the illicit market, few experts suggest the immediate wholesale removal of opioids from health care. | 123RF Stock Photo
As the United States continues to struggle with its growing opiate overdose problem (a record 33,000 deaths in 2015 and an annual $78.5 billion price tag on abuse, according to the latest data available), physicians and policymakers are ramping up their push of alternatives for patients seeking pain relief.
In 2016, St. Joseph’s Regional Medical Center — a New Jersey hospital that bills its emergency department as one of the busiest in the country — began using opioids as a subordinate option. Physicians there first treat such maladies as back pain, broken bones and kidney stones with other available tools: trigger-point injections, nitrous oxide, non-opiate medication and nerve blocks.
Nerve blocks involve injecting medicine with a needle — often guided by ultrasound for precise placement — to numb nerves in a specific area of the body. They have emerged as perhaps the most widely regarded and used opioid alternative. A technique dating more than a century, nerve blocks have been an effective pain reliever for knee replacements, mastectomies with reconstruction and cancer-related pain, to name a few ailments highlighted in studies published since 2012.
“I don’t know that this is a direct response, but I think the movement toward new modalities … has certainly been pushed by the opioid crisis,” says Knox Todd, MD, MPH, FACEP, director of the pain-resource organization EMLine and a former chair of the University of Texas MD Anderson Cancer Center’s Department of Emergency Medicine.
In 2016, the Centers for Disease Control and Prevention released its recommendations on opioids for physicians treating patients with long-term pain — outside of cancer or terminal illness. Among the main points: non-opioid treatment for pain is preferred; when opioids are prescribed, patients should receive the lowest possible effective doses; and physicians should use caution with such prescriptions and monitor patients closely.
In line with non-opioid treatments, Oregon — where three people die weekly from overdosing on prescribed opioids — has started covering alternative treatments for Medicaid patients.
“They have a lot of things in there: physical therapy, cognitive behavioral therapy, acupuncture, chiropractic, yoga, massage,” says Cheryl Ritenbaugh, PhD, MPH, a retired professor of family and community medicine and of anthropology at the University of Arizona. “It’s not a short list.”
Though such treatments aren’t new, Western medicine embracing them is a significant change, especially considering how they were viewed up to the 1990s and early 2000s, Ritenbaugh said.
Physicians who preached the benefits of these unconventional techniques “were quacks,” Ritenbaugh says. But with supportive research, notably with acupuncture, such therapies are becoming more accepted as pain fighters.
“The nonbelievers, if you will, in acupuncture really have to be nonbelievers in science at this point,” she says. “You have to say, ‘I will not believe in the scientific result,’ which, as a physician, is a hard thing to say.”
Ritenbaugh also notes marijuana — which, as of April 2017, was medically legal in 28 states and altogether legal in eight plus Washington, D.C. — as a burgeoning opioid alternative. She points to a 2014 study in JAMA Internal Medicine that found that states with legal medical marijuana had a 25 percent lower rate of opioid overdose deaths than those without it.
Yet even as the discussion on alternatives widens, some physicians maintain nothing compares to opioids — oxycodone, hydrocodone, morphine and the like.
“There’s a real push for physicians to get people going in the other direction, to get them off opioids. It’s real popular right now to say, ‘Get them off opioids, and get them onto some other treatment,’ ” says Brian Ilfeld, MD, MS, a professor in residence of anesthesiology at the University of California, San Diego.
“The problem is that … we really don’t have that some other treatment that’s so great.”
Nerve blocks, for example, are guaranteed to work when applied, but not as a long-term solution, he says. Another alternative specific to back pain, spinal-cord stimulation via electrical signals, is not addictive and can be used forever, but it isn’t particularly effective.
So Ilfeld says he considers opioids a blessing to humans, and medicine wouldn’t be the same without them.
Todd agrees about their effectiveness: “We have millennia of use of opioids, and there’s nothing that works as well to control acute pain.”
To envision what U.S. health care would look like without opioids, consider countries without them, Todd says. In Ghana and Sudan, for example, few patients receive opioids, and this lack of pain control can lead to a host of other issues — trouble breathing, immobilization, prevention of the pursuit of physical rehabilitation, and simple agony, especially in the dying, he says.
“That’s the consequence of making opioids so hard to get that they can’t be used,” he said. “These are inhumane conditions that a first-world country … would not tolerate.”
Ilfeld acknowledges there is misuse: patients selling their pills or seeking them out as a street drug beyond a prescription and becoming addicted. But he says that’s not physicians’ fault — for opioids or any other drug.
“Either a physician treats their patient as best they can, which we’re sworn to do, or we don’t,” Ilfeld says. “Opioids are not inherently bad drugs, per se. Every single drug we have has side effects. There’s no exception.”
Looking forward, despite overdoses and the illicit market, few experts suggest the immediate wholesale removal of opioids from health care. Even Ritenbaugh recognizes the monumental task.
“Big Pharma wants to keep selling pain relievers; physicians only understand pain relievers; hospital systems are built around assumptions about how long you have to stay after surgery and what kind of treatment you need, and they’re highly resistant to getting a different result,” she says. “So I think we have a long way to go.”
However, something that might lead patients to seek one alternative in particular — acupuncture — would be cuts to the U.S. health care system. Such treatment is more affordable than hospital stays, Ritenbaugh says.
Todd figures providing opioids to patients being treated for intense, acute pain — such as those caused by severe burns, broken bones and ankle sprains — will “only diminish slightly.” Any big changes will instead come from what those patients are sent home with.
“Instead of prescribing 30 pills to a patient routinely, we’ll see more often a person prescribed 10 or 12 pills,” he says, adding that this will decrease the likelihood for dependence or the medicine ending up in the wrong hands.
It is likely opioids always will be abused to some degree, Ilfeld says, but long-shot efforts are being crafted in the form of roadblocks in the medicine itself. He notes the special formula used in recent years for OxyContin pills that’s designed to prevent them from being crushed, so users cannot make a powder for snorting or injecting to get an instant high. (Indeed, in a video demonstration by Forbes magazine, the pill stays intact after being hit with a hammer.)
“I think it’s going to be very difficult to ‘pharmacology’ our way out of this problem, although it’s certainly being tried,” Ilfeld says. “And God bless them for trying.”
Michael Stone is a freelance health care writer based in Florida.