PAIN RELIEF IN THE ANTI-OPIOID ERA

Give your patients the pain relief they seek

Pain erodes overall quality of life by impairing the ability to work, play, or simply manage the activities of daily living. It is the most common symptom that drives patients to seek immediate care, says Rosemary Carol Polomano, PhD, RN, FAAN, professor of pain practice at the University of Pennsylvania School of Nursing in Philadelphia.

Guiding Principles

When patients with pain get to your clinic, they’re uncomfortable and frustrated and may be expecting medications they’ve received in the past, namely opioids. But the foundation of acute pain management is now nonopioid medication and other, nondrug techniques.

February 2021 marked the culmination of a two-year project spearheaded by the American Society of Anesthesiologists (ASA) aimed at curtailing opioid abuse. Fourteen medical groups developed guidelines to help decrease an overreliance on opioids, increase access to care, and promote widespread education on pain and substance-use disorders.

It established guiding principles that are based on multimodal and multidisciplinary approaches to pain management, including nonpharmacologic interventions, the use of validated pain assessment tools to guide and adjust treatment, and an emphasis on individualized care and education.

Role of Opioids

The guidelines don’t remove opioids from the arsenal of pain management tools, but they do redefine their role as a short-term solution.

“There will still be times when an opioid is used—for a patient passing a kidney stone, for instance, or recovering after surgery—with right-sized dosing and monitoring,” says David M. Dickerson, MD, chair of the ASA’s committee on pain medicine and medical director of Anesthesia Pain Management Services at NorthShore University Health System in Evanston, Illinois. “Using a multiprong approach to pain means that the core of pain control is with modalities that can still be used when any course of opioids is over,” he explains.

Pain-Management Modalities

The foundation of acute pain management is often acetaminophen, but a patient may need a second layer of pain treatment, such as a topical numbing agent, muscle relaxant, or heat, ice, and elevation. Within convenient-care settings, here are the most helpful pain management modalities.

Over-the-counter Analgesics

Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Brufen, Advil, Motrin, Nurofen) and naproxen (Aflaxen, Aleve, Anaprox, EC Naprosyn, Naprelan) are often the first line of treatment for short-term use.

NSAIDs are meant to be taken at the recommended dosage for a four- to six-day period. The longer patients take NSAIDs, the greater the risk of cardiovascular issues, gastrointestinal dysfunction, kidney problems, and increased bleeding time. “It’s always important before prescribing any analgesic to know the patient’s health history, especially any hepatic, gastric, or renal issues,” says Dr. Polomano.

Acetaminophen (Tylenol, Paracetamol, Panadol, Aceta) can cause liver toxicity if taken for too long or in dosages that are too high. The American College of Gastroenterology notes that healthy people should take no more than 1,000 mg of acetaminophen per dose or 4,000 mg per day. If a patient has liver disease, acetaminophen intake should not exceed 2,000 mg per day. Healthy people should also avoid taking 3,000 mg of acetaminophen daily for more than three to five days. Patients should undergo liver-function testing, avoid drinking alcohol, and include the drug on their medication list any time another health-care provider asks what drugs they take regularly.

At a Glance

• Fourteen medical groups joined together to develop guidelines to help decrease an overreliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders.

• The guidelines don’t remove opioids from the arsenal of pain management tools, but they do redefine their role as a short-term solution.

• Nonopioid pain-relieving treatments may include OTC medications, steroids, anticonvulsants, antidepressants, heat, cold, and transcutaneous electrical nerve stimulation.

• Exercise and diet play an important role in pain management.

• Several evidence-based mind-body techniques that activate descending pathways from the brain to the site of the pain can be helpful.

Steroids

For acute pain, such as back pain that radiates down the leg, a short course of steroids can help decrease inflammation and pain. But these drugs shouldn’t be prescribed long term because of their side effects, says

Grant Chen, MD, associate professor of anesthesiology and chief of chronic pain services at McGovern Medical School at UTHealth, Houston.

Anticonvulsant Drugs

Pregabalin (Lyrica) and gabapentin (Horizant, Gralise, Neurontin) can help with neuropathic and muscular pain. A small study published in October 2021 in The Korean Journal of Pain explained that pregabalin seems to work by interrupting “the immune system’s role in the pathogenesis of neuropathic pain.” These drugs are relatively safe, but not all patients respond to them, notes Dr. Chen.

Antidepressants

Drugs such as duloxetine (Cymbalta) and venlafaxine (Effexor) can help with neuropathic pain. You may need to explain to patients that you are not suggesting that their pain is caused by depression, but that these drugs can affect how the brain perceives pain. Start patients at a lower dose to reduce the risk of side effects, such as sedation or dizziness, and then increase as needed. Make sure your patients know that they should follow up with you if they are not experiencing relief within four to six weeks: A dosage increase or medication change may be needed.

“These drugs need to be titrated slowly, especially if the patient is older and if the drugs contribute to sedation,” Dr. Polomano says.

Heat and Cold

Temperature and pain travel on the same nerve fibers. A cold compress is one of the most effective approaches to reduce drivers of pain, like inflammation, says Dr. Dickerson. For some conditions, such as a pulled muscle, heat might be more helpful. Advise patients to follow a pattern of 20 minutes on and 20 minutes off.

Creams

Over-the-counter products like Salonpas, Icy Hot, lidocaine cream, and diclofenac gel can provide relief. Both lidocaine patches and diclofenac are also available in prescription strength if needed, says Dr. Chen.

Transcutaneous Electrical Nerve Stimulation (TENS)

These at-home units send low-voltage electrical signals that either interrupt the nerve signals to the brain or stimulate the production of endorphins. A study published in the Journal of Pain Research found that using a wearable TENS device reduced disease impact, pain, and functional impairment in people with fibromyalgia. Participants with higher pain sensitivity exhibited larger treatment effects than those with lower pain sensitivity.

Exercise

Lifestyle changes can have an important impact on pain relief, but these changes aren’t quick fixes. They take dedication and time.

“The main lifestyle change is to be more active in whatever way you can,” says Dr. Chen. “Exercise can help patients lose excess weight and strengthen muscles around painful sites.” Dr. Chen finds tai chi to be particularly effective.

Even right after surgery, he encourages patients to move, especially when they are in the hospital and receiving pain medication. “The worst thing is lying in bed and letting muscles atrophy,” he says. “Injections and medications cover up pain but don’t change the body structurally. Doing physical therapy and strengthening the core can really help with long-term pain relief compared to short-term office treatments.”

While exercise is important, “you need to know the pain syndromes that need rest vs. those that need increased mobility to prevent further pain. For example, if the patient has shoulder pain, there are some conditions that benefit from musculoskeletal immobility for a short time and others that need immediate mobilization. Sending a patient to an ambulatory physical therapy setting as an adjunct to analgesics is appropriate,” says Dr. Polomano. A physical therapist can tailor an exercise program to pain and may use other modalities, including ultrasound and massage. Water exercise can make exercise less painful as well.

Diet

According to research published in Pain and Therapy, diet may play a supporting role in easing pain. The theory is that chronic pain stems, in part, from oxidative stress and inflammation, conditions that are linked to diet. The standard American diet has been linked to “increased postprandial oxidative stress in the short term and chronic elevation of oxidative stress markers in the long term.” This is most likely because it increases free radicals and hinders the antioxidant defense system.

Switching to a low-carbohydrate diet or Mediterranean diet can reduce pain in some patients. “Some people find that including turmeric in their diet may also help to decrease inflammatory pain,” says Dr. Chen.

Developing a Plan

To provide the best care, first evaluate the person and their pain. When a patient comes to your clinic, you may have only limited knowledge of that person’s history, which can make it challenging to diagnose and treat their pain. The first step, then, is to evaluate the pain in the context of other symptoms and determine whether the pain is acute or chronic.

Acute pain can come from identifiable sources—strains, pulled muscles, herpes zoster, or a recent surgery—or it can be

Mind-Body Techniques

Several evidence-based mind-body techniques that activate descending pathways from the brain to the site of the pain can be helpful.

Acupuncture. “Although used for a variety of ailments, in the West, acupuncture has a history of treating mostly pain. It is completely natural, safe, and effective in that all it’s doing is stimulating the body to heal itself,” says Judith Woolf, MAc, LAc, a licensed acupuncturist in Ridgefield, Conn.

“By targeting specific points, we can stimulate the immune system and release endorphins and other chemicals like serotonin and norepinephrine, which help ease pain,” she says. “It not only treats the pain, but also brings blood to the area to promote healing.” Acupuncture can be combined with other modalities.

Mental health therapy. “Pain is a physical and emotional response to potential or current tissue damage. … Pain can get into the patient’s head to the point where they focus on pain and nothing else,” says Dr. Chen. Strategies such as cognitive behavioral therapy can help patients understand where their pain comes from, how it manifests, and how to manage the anxiety that comes with it.

You can research evidence-based treatments in the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine publication Acute Pain Management: Scientific Evidence. It’s available as a free download at https://www.anzca.edu. au/resources/college-publications/acute-painmanagement/apmse5.pdf

more mysterious. A patient may complain of low-back pain, but determining the actual source of the discomfort can be complicated: Is the pain from a joint, a muscle, a herniated disc? Does it stem from an acute injury? Or could it be an exacerbation of a chronic problem? “Then you can maximize multimodal analgesia—combining different classes of drugs, such as nonopioids, acetaminophen, and an SNRI [serotonin-norepinephrine reuptake inhibitor], for instance, with different mechanisms that target pain by different pathways,” Dr. Chen notes.

While acute pain often responds well to nonopioid treatments, chronic pain is more challenging to address. Helping a patient resolve a chronic pain condition requires a different approach and often starts with getting them an exact diagnosis. That can mean referring them to a pain specialist.

As a convenient-care clinician, your role is to help guide patients to the care they need. “You have the ability to recognize when a patient is not recovering and when to involve a pain specialist. Many pain specialists come from other medical specialties, such as anesthesiology, emergency medicine, rehabilitation, or even psychiatry. What they all have in common is that they take a 360-degree approach to addressing pain.

Medical Interventions

Pain specialists have an arsenal of treatment options to help relieve chronic pain, many of which patients may not be aware of. • Nerve blocks. These injections of local anesthetics or other medications can help short-circuit nerve pain or pain from a muscle spasm. • Noninvasive brain stimulation. According to research published in Pain and Therapy, the two most commonly used technologies, repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), relieved pain symptoms in 97.1% and 81.4% of neuropathic pain patients respectively. • Radiofrequency ablation. This procedure uses an electric current created by radio waves to short circuit the nerves that transmit pain signals. Relief can last for up to one year. • Neuromodulation. This umbrella term refers to a number of treatment modalities that reroute pain signals. They include spinal cord stimulation, which uses a pacemaker-like device that replaces the pain with a more tolerable sensation; implanted systems that allow spinal-pain patients to deliver medication directly to the painful area at the press of a button; and sacral, brain, peripheral nerve, and peripheral nerve field stimulation. Neurostimulation can help pain from a nerve injury, slow healing after surgery, and the burning pain caused by diabetes. “There’s a 70 to 80% response rating in patients for whom it’s appropriate,” says Dr. Dickerson. • Interspinous spacers. These small implants can restore 1 centimeter of height to spinal areas affected by degenerative issues such as herniated discs and spinal stenosis, in which narrowing pinches nerves and causes pain. The procedure is minimally invasive but must be performed by a specialist with specific training in the procedure. • Future trends. Research into other procedures, such as regenerative medicine using stem cell implants, is ongoing, says Dr. Chen. But for some patients, only surgery will correct abnormalities responsible for their pain. It may be the answer for people who can no longer tolerate their pain level, for whom a condition has caused disability or severely affected daily living, or when everything else fails to help enough. C