Speakers - 2027

Title: Expanding the role of integrative medical practices acute and chronic pain management

Abstract

In 2007, a review article1 by international experts in pain management encouraged the more widespread use of opioid-containing analgesics by suggesting that “if only we [physicians and nurses] could overcome our ‘opiophobia’, we would improve pain management”. In an accompanying editorial, I argued that ‘less may be more’ with respect to the use of opioid [narcotic] analgesics,2 and that using an integrative approach using non-opioid analgesics and non-pharmacologic techniques to reduce the dependence on oral and parenteral opioid analgesics would reduce the risk of opioid-related side effects, including nausea, vomiting, constipation, ileus, bladder dysfunction, pruritis, sedation, hallucinations, ventilatory depression, as well as long-term physical dependence and addiction liability. Even short-term use of potent opioid analgesics during the intra-operative period can actually aggravate pain due to opioid-induced hyperalgesia (i.e., acute tolerance).3,4 Although opioids are highly effective in providing short-term relief of acute pain, they do not treat the underlying disease process. In fact, recent retrospective studies suggested an association between the use of large doses of opioid analgesic medication during the perioperative period in patients undergoing primary cancer surgery and increased cancer recurrence rates.5

In 2014 16,790 deaths were reported in the USA secondary to overdosing with prescription opioids. Recently, the Centers for Disease Control and Prevention (CDCP) conducted a review of the benefits and harms, values and preferences, and costs of opioid use for chronic pain.6 These authors concluded that long-term opioid use was associated with increased risks of opioid use disorder, overdose, and death, and studies have failed to demonstrate any long-term (≥1 year) benefits. In an epidemiological study by Eriksen et al7 involving chronic pain patients treated with opioids for 5 yr, these investigators provided compelling evidence that opioids were not a panacea for chronic pain. In fact, the patients’ quality of life failed to improve despite escalating doses of opioids over the 5 yr study period. These authors concluded that “it is remarkable that opioid treatment of long-term chronic non-cancer pain does not seem to fulfill any of the key outcome treatment goals, namely, pain relief, improved quality of life and improved functional capacity.” Furthermore, opioid analgesic therapy aimed at alleviating chronic pain may actually aggravate the situation due to opioid-induced hyperalgesia.3,4 

In excess of 10 million people in the United States were reportedly using prescription opioids for nonmedical reasons in 2014, and 2.1 million people met diagnostic criteria for a substance use disorder involving prescription opioids.8 This was the highest number of individuals considered to have an opioid addiction since the late 19th century. According to the US Surgeon General, despite spending in excess of $35 billion on rehabilitation programs for opioid dependent patients in this country, only 10% of patients with a substance abuse problem involving opioid-containing medications are receiving treatment.9 Pharmaceutical companies manufacturing opioid medications [and allied groups (e.g., Pain Care Forum)], spent more than $880 million in 2015-16 on campaign contributions to lobby politicians at the state and federal government level to block legislation aimed at curtailing the use of opioid analgesics. Although heroin use in this country declined in the 1990s as prescription opioid use soared, its use is resurging as prescription opioids are becoming more difficult to obtain and black-market drugs like heroin and the newer fentanyl analogs are less costly and easier to obtain. Currently, 4 out of 5 individuals initiating heroin use report starting with a prescription opioid. Sadly, the public is now paying a huge price for ignoring the early warnings regarding risk of more widespread opioid use for acute and chronic pain management. Recent articles from the CDC have recommended increasing use of non-opioid and non-pharmacologic approaches (e.g., cognitive behavioral therapy, acupuncture, physical therapy) in the management of chronic pain.6,8

The ‘liberalization’ of opioid use for acute and chronic pain management1 and the institution of pain ‘as a 5th vital sign10,11 has led to more aggressive use of opioid analgesics in the medical community. The 5th vital sign utilizes a simple 11-point verbal numerical pain scoring system (0=no pain to 10=intolerable pain) and is now a mandatory part of the clinical assessment of pain by many healthcare organizations in the USA. Interestingly, routinely measuring pain as the 5th vital sign has produced inconsistent effects in improving the quality of pain management.10,11 However, this controversial clinical practice has led to an increase in the average dosages of opioid analgesic medication administered to hospitalized patients and increased the incidence of adverse drug reactions (e.g., opioid “over sedation”)and in-hospital opioid overdoses and opioid-related deaths after major elective surgery procedures.12 Of the patients experiencing life-threatening adverse reactions to opioid analgesics (e.g., respiratory and/or cardiac arrests), >90% had a documented decrease in their level of consciousness preceding the event.10 Concomitant use of sedative-hypnotic and gabapentannoid drugs contributes to the increase in opioid-induced sedation. In addition, use of an opioid infusion after surgery increases the risk of opioid-overdosing without reducing postoperative pain scores, the number of nocturnal awakenings, or opioid-related side effects compared to traditional intermittent bolus dosing of opioid drugs.13 Use of continuous infusions is ‘outside the norm’ and not a best practice outside of the context of patients with acute pain who have underlying chronic pain requiring high doses of opioid analgesics. On the other hand, the adjunctive use of non-opioid analgesics like ketorolac (a potent parenteral non-steroidal anti-inflammatory drug [NSAID]) and celecoxib, can significantly reduce the opioid requirement and opioid-related adverse reactions during the postoperative period and facilitate the recovery process.14,15 Unfortunately, misinformation regarding the bleeding risk and other side effects associated with the short-term use of NSAIDs (and COX-2 inhibitors) has made some physicians reluctant to administer these valuable analgesic adjuvants during the perioperative period.

What will the audience take away from your presentation?

1.Learn techniques for reducing the need for opioid analgesics during and after surgery.

2.Describe the use of multimodal (‘balanced”) analgesic techniques.

3.Description of non-pharmacologic techniques used to treat acute and chronic pain