Alternatives to Opioids: New innovations in pain management
Pain management has been an ongoing facet of healthcare for generations. However, as the challenges of opioid addiction rage through the country and states like Michigan adopt new regulations, physicians, caregivers and health systems are pursuing new medical and intervention strategies to treat patients for acute and chronic pain.
“The entire outlook of pain management has been affected by the opioid crisis,” said Christina Eickenroth, RN, BSN, opioid coordinator, clinical quality at Munson Medical Center.
Eickenroth integrates the work of the Munson Healthcare Opioid Workgroup into the system’s response to the opioid crisis including education for patients and providers, ensuring safe prescribing practices, improved identification of abuse and addiction, and pain management. Prior to her current position, Eickenroth had worked on a surgical/telemetry unit.
“Pain management of post-surgical patients is drastically different than it was just a couple of years ago,” she said. “The expectation used to be that patients will not feel pain and, as healthcare professionals, we were taught to classify pain as the fifth vital sign [others are blood pressure, pulse, temperature and oxygenation].”
Today’s best practices range from prevention, perception and pre-operative planning to non-opioid medications, nerve blocks and spinal cord stimulation.
SHIFTING PERCEPTION, STRATEGIES
Eickenroth says that shifting patient perceptions about pain after surgery is an important advancement. She notes some pain is to be expected, normal and healthy, and can provide warning signs during the recovery process.
“The culture surrounding post-op pain management is not an easy shift for either side but there are methods that are helpful,” she said, noting such simple techniques as ice, heat, meditation, breathing and relaxation as well as keeping a calm and quiet environment. A newly developed Nurse Navigator program works with patients before surgery to identify needs and barriers that could impact pain management.
Newer strategies for surgical patients include using the non-opioid medication gabapentin, which acts on the central nervous system to chemically adjust the perception of pain versus an opioid or nonsteroidal medication reducing pain. Another new technique, directed at reducing incisional pain, is to use a nerve block or numbing a surgical site prior to the first cut, in addition to the procedure’s regular anesthesia.
Within several surgical specialties, collaborative quality initiatives (CQI) have formed to collect data and improve patient outcomes, including pain management. Michigan Opioid Prescribing Engagement Network (MI-OPENS) takes a preventive approach by focusing on acute care prescribing and practices in surgery, dentistry, emergency medicine and trauma. Eickenroth notes that many surgical service lines participate in CQIs and MI-OPENS works within many areas to institute recommendations.
According to Ward Gillett, MD, at Bay Area Urology Associates, Traverse City urologists have been part of the statewide Michigan Urological Surgery Improvement Collaborative (MUSIC) since it formed in 2011, joining with 52 other practices and over 200 physicians in a consortium focused on improving quality of prostate cancer care. This CQI later led to MUSIC ROCKS (Reducing Operative Complications from Kidney Stones). By collecting and sharing patient data from a broad range of communities and clinical practices, urologists locally and across the state are recognizing and addressing issues that could cause post-surgical pain. Benefits include greater consistency in treatment and prevention strategies, resulting in reduced post-surgical pain and related emergency room visits.
Patients with severe chronic pain require more complex approaches such as those addressed at the Munson Healthcare Pain Clinic located at Munson Community Health Center.
When the pain clinic opened in 1991, one physician saw patients one day per week. Today, the multidisciplinary clinic runs five days per week with four physicians, two psychologists, two nurse practitioners and three physical therapists on staff. Treatment options are broad and individualized to each patient, ranging from topical and oral medications, non-opioid alternatives, exercise and physical therapy, implantable medication delivery systems, nerve stimulators and interventional procedures. The role of depression in chronic pain management is also addressed.
Anesthesiologist Richard Burke, MD, is one of four pain clinic physicians. Board certified in pain management as well as anesthesia, Dr. Burke specializes in spinal cord stimulation utilizing a new generation of implantable technology that has been successful for patients experiencing significant nerve pain such as those with severe back or neck issues.
“Most of these patients have failed back or neck surgery, and are left with no further surgical options,” he said, noting that chronic pain emanating from the central nervous system is constant and does not diminish with rest or at night. Stimulators have occasionally been used in the head, for post trauma, some strokes and some partial nerve cord issues.
Battery operated nerve stimulators are implanted in the body and provide ongoing stimulation to the spinal cord, offering relief from constant pain. After implantation, batteries are replaced about every 10 years. While electrostimulation has been an option for years, the new generation of technology is smaller, longer lasting and more accessible and effective.
Dr. Burke implants about eight stimulators per month.
“This is one of the greatest areas of change within the practice of pain management,” he said. “The real heroes are the engineers who developed this [technology].”
According to Dr. Burke, another pain clinic procedure that addresses neck pain are cervical rhizotomies, a minimally invasive procedure also known as radiofrequency ablations, that cauterizes the pain-causing nerves that cause pain which eliminates the transmission of pain signals to the brain.