The increasingly widespread use of opioid painkillers for chronic pain has created a public health crisis as many people are abusing these highly addictive medications.
Aiming to reduce the number of opioid prescriptions doctors write, the Centers for Disease Control and Prevention recently issued guidelines that recommend doctors try pain relievers like ibuprofen before prescribing the highly addictive pills, and that they give most patients only a few days’ supply.
But pain intervention specialists actually have a number of other alternative treatments that may address chronic pain with little or no medication.
Today, Dr. Erik Shaw of Shepherd Spine and Pain Institute addresses the opioid crisis and explains some pain interventions that are helping patients manage their condition without addictive painkillers.
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Alternatives to Treating Pain with Opioid Medications
Featured Speaker:
Learn more about Erik Shaw, DO
Erik Shaw, DO
Erik Shaw, D.O., is an interventional pain management specialist at the Shepherd Spine and Pain Institute. Dr. Shaw is double board certified in physical medicine and rehabilitation and pain medicine. A Texas native, Dr. Shaw graduated from Texas A&M University with a degree in biomedical engineering and earned his medical degree at the University of North Texas Health Science Center in Fort Worth.Learn more about Erik Shaw, DO
Transcription:
Melanie Cole (Host): The increasingly wide spread use of opioid pain killers for chronic pain has created a public health crisis as many people are abusing these highly addictive medications. However, a pain interventionalist and specialists actually have a number of alternative treatments that may address chronic pain with little or no medication. My guest today is Dr. Erik Shaw. He is an Interventional Pain Management Specialist at Shepherd Spine and Pain Institute. Welcome to the show, Dr. Shaw. First tell us, what are opioid medications and what are they used for?
Dr. Erik Shaw (Guest): Opioid pain medications are derived from the opium poppy and are powerful analgesics or pain relievers that help both pain after surgery or after trauma and can be used sometimes for patients that suffer severe chronic pain after a long term injury or degenerative disease such as degenerative back disease or lumbar disc disease.
Melanie: Are opioids generally considered safe?
Dr. Shaw: That’s a loaded question and can be very nuanced in its answer. Roughly speaking, in trained hands – with an expert – opioids can be safe. There is little data to suggest that they have long term efficacy for chronic pain. That being said, in select patients if you monitor them carefully for improved function, quality of life and overall well-being and monitor side effects, they can be very helpful. But, they can cause addiction. Patients can misuse them. They can put patients at risk for significant complications such as constipation. When mixed with other central nervous system depressants, like alcohol or medicines like Valium or Xanax, they can significantly compromise the respiratory drive, putting the patients at risk for respiratory arrest and death. They can be helpful but they need to be monitored carefully and the doses generally are thought to have somewhat of a feeling of safety in the long-term efficacy perspective. Some practitioners don’t necessarily agree with that and they will escalate the dose as long as they are monitoring the patient for quality of life and function. I think that can be reasonable. But, they need to be monitored carefully by someone that has a lot of experience.
Melanie: What is and what isn’t known about long term use of opioids? Do some people have to stay on these things for their chronic pain and does that mean that they’re necessarily addicted to them?
Dr. Shaw: Just because someone has been on a medication for five or ten or twenty years doesn’t mean that they’re addicted. It will cause dependence and tolerance. Anybody may know that chronic use of opioids may decrease in efficacy or function, in terms of relief of pain, the longer that they’ve been on it. They may need to increase their dose and that’s called tolerance. Dependence is if you stop the medication abruptly, they’ll have a withdrawal syndrome for it. Addiction is where you are misusing the drug or using it to get other illegal substances or engaging in detrimental self-harm or harm to others in order to obtain more of the same medication. That’s addiction. While it’s generally regarded to be between two and fifteen percent depending on the study that you want to quote, it’s not necessarily all of the patients. Just because they have been on a medication for an extended period of time doesn’t mean that they are all addicted to it. It does usually mean that the other two definitions that I gave are applicable, however.
Melanie: Due to this risk of misuse and addiction, Shepherd Pain Institute ventures beyond narcotics to treat pain. Tell us about some of the things that you do that are non-narcotic pain relievers.
Dr. Shaw: Absolutely. If we’re taking low back pain as an example which is a very common complaint among our population here in the United States, there are many things that can be done depending upon the diagnosis, the severity of the pain, and the functional limitations to the patient. As physical medicine rehabilitation specialists, we take into account all the functional, quality of life, and adjunctive issues in terms of depression, work status, relationship with family and others that may be impacted by the pain and look at the exact diagnosis, whether it be degenerated disc disease or pinched nerve, or muscle sprain and address that specifically. Any number of injections can be done that are relatively simple, done either at the bedside with ultrasound or under fluoroscopic guidance, which is a live x-ray beam under relatively low power, to see if you can target the pain and relieve it in conjunction with physical therapy and sometimes with psychotherapy. We can use non-opioid medications which can be very helpful and sometimes physical therapy is very appropriate to help the patient regain function and improvement. It helps them to understand how they can move and exercises they can do that will not be harmful to them just because they’re experiencing pain.
Melanie: As no two patients experience pain the same way, how do you determine from a patient how much pain they’re really in?
Dr. Shaw: No one has come up with a pain-o-meter yet. I’m hoping that sometime in the future someone will discover one but until that happens, you have to take into account lots of different factors: behavior, pain rating, demeanor, function on physical exam to make sure everything makes sense. Sometimes when patients are experiencing a significant amount of pain but their disease state, their x-rays and MRI and their physical exam is not that compromised. That’s when a psychologist may be able to help them to get a few more coping skills. They may have depression as their primary issue and pain is simply a manifestation of it. They may have had an emotional trauma that has led to pain and it could be helped with psychology as well. It’s important to look at all facets of a person that helps the total person that sometimes includes medications. Sometimes it includes physical therapy. Sometimes it includes injections. Sometimes it includes psychotherapy. Sometimes it includes all of it. It’s important to individualize the therapy for each patient dependent upon their specific needs.
Melanie: You mentioned medication. With these other therapies, is sometimes medication also something that you might use so that they would go along as co-therapies?
Dr. Shaw: Absolutely. Medication can be very helpful. The goal is to wean or to reduce the medication as the patient tolerates it and starts to get stronger and more active. Sometimes that’s not possible. Sometimes somebody has a chronic condition that can’t really be improved such as severe scoliosis of the spine which can happen as we age. That might not be amenable or helped by surgery or the risk of surgery maybe much greater. Those kinds of issues tend to be very difficult to treat in a simplistic way. Some medications which are in the opioid family are generally a little bit safer and have a little bit less risk to them. Unfortunately, they are also more expensive and insurance companies don’t always want to pay for them. It’s the classic struggle from the provider trying to prescribe what they think is in the best interest of the patient and then having financial challenges to see that therapy through. It’s always something that we struggle with that we balance the risk with the cost of all of these different things and try to move the patient forward overall.
Melanie: Explain a little bit about neuromodulation, Dr. Shaw, and how that works for people to help control their pain.
Dr. Shaw: Some of the approved indications are chronic low back and leg pain after spinal fusion surgery. A lot of times, after spinal fusion surgery somebody may continue to have low back pain or their original low back pain may be replaced with a new back pain after the surgery and they may also continue to have leg pain. Spinal cord stimulation, which is the most common type of neuromodulation is a small electrode that is placed on the epidural space floating behind the spinal cord, frequently in the area of the lower several rib, sometimes in the middle of the thoracic spine which the thoracic spine is where the ribs are, or even sometimes in the upper, depending upon which part of the body you’re trying to cover. It tends to cover up the pain with a pleasant tingling, vibration kind of sensation which the patient finds more pleasurable and pleasing than the pain. There’s a trial period which is usually four to seven days and then, if that trial is successful, hopefully, with at least 30-50% reduction in pain as well as improvement and function and reduction in pain medication, then that patient can be thought to be a successful candidate and go onto permanent implantation of the device. The leads are, therefore, then placed permanently in the spine in a place floating behind the spinal cord. The battery is placed usually in the hip or the flank under the skin. You can think about it like a pacemaker for pain. It blocks the pain signal and replaces it with a vibration or a tingling which generally allows a patient to be more functional, have a better quality of life, be more active and take less medication.
Melanie: So then, speak about biofeedback as a treatment option and a coping mechanism because a lot of the issues with pain is how much you can tolerate and being able to live that quality of life.
Dr. Shaw: Sure. Anybody listening to the program may have noticed that they have more pain when they’re stressed out or they get a headache and this is all because of the body’s response to stress. Biofeedback and different kinds of coping mechanisms, which are the psychological aspects of what we do, can really be helpful in helping to reframe and give patients alternate ways to deal with the pain rather than just taking a pill. It’s, obviously, more helpful for some patients that really understand how this is important and viable for their life and some patients just don’t understand that concept and have a difficult time really incorporating it into their lives. Nonetheless, it’s applicable and suggested for the majority of our patients and sometimes it’s very successful and you go on to have very successful reduction or elimination of pain medication with little or no other treatment other than the biofeedback or the coping mechanism. Sometimes it allows the patient to tolerate and be ready to accept the next stage of treatment, whether it be an injection or different medication or neuromodulation.
Melanie: In just the last few minutes, Dr. Shaw, please explain a little bit about the Shepherd’s Spine and Pain Institute and your multidisciplinary approach.
Dr. Shaw: Sure. We have two physicians, one nurse practitioner, four nurses, four MA’s, two psychologists and a physical therapist. We all work together as a team-oriented approach to help the patient in all of the multifaceted ways that we have just been discussing. Each person on the team has their individual role but we all work together because a lot of times, the nurses will remind me about something that maybe I hadn’t considered for a certain patient or I will remind the nurses to educate them about the TENS unit which is a skin device that can cause tingling as well. The psychologist may bring up an aspect of their life which I wasn’t aware of which could help me to focus my treatment with a different medications or send them to another specialist. We all work together. We discuss these patients on a regular basis to help and to augment different aspects of their lives to improve function and their quality of life and to maximize it to whatever extent is possible given their given condition. That’s really what a good multidisciplinary team of pain approach should include.
Melanie: Thank you so much for being with us today, Dr. Shaw. It’s great information. You’re listening to Shepherd Center Radio and for more information you can go to Shepherd.org. That’s Shepherd.org. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): The increasingly wide spread use of opioid pain killers for chronic pain has created a public health crisis as many people are abusing these highly addictive medications. However, a pain interventionalist and specialists actually have a number of alternative treatments that may address chronic pain with little or no medication. My guest today is Dr. Erik Shaw. He is an Interventional Pain Management Specialist at Shepherd Spine and Pain Institute. Welcome to the show, Dr. Shaw. First tell us, what are opioid medications and what are they used for?
Dr. Erik Shaw (Guest): Opioid pain medications are derived from the opium poppy and are powerful analgesics or pain relievers that help both pain after surgery or after trauma and can be used sometimes for patients that suffer severe chronic pain after a long term injury or degenerative disease such as degenerative back disease or lumbar disc disease.
Melanie: Are opioids generally considered safe?
Dr. Shaw: That’s a loaded question and can be very nuanced in its answer. Roughly speaking, in trained hands – with an expert – opioids can be safe. There is little data to suggest that they have long term efficacy for chronic pain. That being said, in select patients if you monitor them carefully for improved function, quality of life and overall well-being and monitor side effects, they can be very helpful. But, they can cause addiction. Patients can misuse them. They can put patients at risk for significant complications such as constipation. When mixed with other central nervous system depressants, like alcohol or medicines like Valium or Xanax, they can significantly compromise the respiratory drive, putting the patients at risk for respiratory arrest and death. They can be helpful but they need to be monitored carefully and the doses generally are thought to have somewhat of a feeling of safety in the long-term efficacy perspective. Some practitioners don’t necessarily agree with that and they will escalate the dose as long as they are monitoring the patient for quality of life and function. I think that can be reasonable. But, they need to be monitored carefully by someone that has a lot of experience.
Melanie: What is and what isn’t known about long term use of opioids? Do some people have to stay on these things for their chronic pain and does that mean that they’re necessarily addicted to them?
Dr. Shaw: Just because someone has been on a medication for five or ten or twenty years doesn’t mean that they’re addicted. It will cause dependence and tolerance. Anybody may know that chronic use of opioids may decrease in efficacy or function, in terms of relief of pain, the longer that they’ve been on it. They may need to increase their dose and that’s called tolerance. Dependence is if you stop the medication abruptly, they’ll have a withdrawal syndrome for it. Addiction is where you are misusing the drug or using it to get other illegal substances or engaging in detrimental self-harm or harm to others in order to obtain more of the same medication. That’s addiction. While it’s generally regarded to be between two and fifteen percent depending on the study that you want to quote, it’s not necessarily all of the patients. Just because they have been on a medication for an extended period of time doesn’t mean that they are all addicted to it. It does usually mean that the other two definitions that I gave are applicable, however.
Melanie: Due to this risk of misuse and addiction, Shepherd Pain Institute ventures beyond narcotics to treat pain. Tell us about some of the things that you do that are non-narcotic pain relievers.
Dr. Shaw: Absolutely. If we’re taking low back pain as an example which is a very common complaint among our population here in the United States, there are many things that can be done depending upon the diagnosis, the severity of the pain, and the functional limitations to the patient. As physical medicine rehabilitation specialists, we take into account all the functional, quality of life, and adjunctive issues in terms of depression, work status, relationship with family and others that may be impacted by the pain and look at the exact diagnosis, whether it be degenerated disc disease or pinched nerve, or muscle sprain and address that specifically. Any number of injections can be done that are relatively simple, done either at the bedside with ultrasound or under fluoroscopic guidance, which is a live x-ray beam under relatively low power, to see if you can target the pain and relieve it in conjunction with physical therapy and sometimes with psychotherapy. We can use non-opioid medications which can be very helpful and sometimes physical therapy is very appropriate to help the patient regain function and improvement. It helps them to understand how they can move and exercises they can do that will not be harmful to them just because they’re experiencing pain.
Melanie: As no two patients experience pain the same way, how do you determine from a patient how much pain they’re really in?
Dr. Shaw: No one has come up with a pain-o-meter yet. I’m hoping that sometime in the future someone will discover one but until that happens, you have to take into account lots of different factors: behavior, pain rating, demeanor, function on physical exam to make sure everything makes sense. Sometimes when patients are experiencing a significant amount of pain but their disease state, their x-rays and MRI and their physical exam is not that compromised. That’s when a psychologist may be able to help them to get a few more coping skills. They may have depression as their primary issue and pain is simply a manifestation of it. They may have had an emotional trauma that has led to pain and it could be helped with psychology as well. It’s important to look at all facets of a person that helps the total person that sometimes includes medications. Sometimes it includes physical therapy. Sometimes it includes injections. Sometimes it includes psychotherapy. Sometimes it includes all of it. It’s important to individualize the therapy for each patient dependent upon their specific needs.
Melanie: You mentioned medication. With these other therapies, is sometimes medication also something that you might use so that they would go along as co-therapies?
Dr. Shaw: Absolutely. Medication can be very helpful. The goal is to wean or to reduce the medication as the patient tolerates it and starts to get stronger and more active. Sometimes that’s not possible. Sometimes somebody has a chronic condition that can’t really be improved such as severe scoliosis of the spine which can happen as we age. That might not be amenable or helped by surgery or the risk of surgery maybe much greater. Those kinds of issues tend to be very difficult to treat in a simplistic way. Some medications which are in the opioid family are generally a little bit safer and have a little bit less risk to them. Unfortunately, they are also more expensive and insurance companies don’t always want to pay for them. It’s the classic struggle from the provider trying to prescribe what they think is in the best interest of the patient and then having financial challenges to see that therapy through. It’s always something that we struggle with that we balance the risk with the cost of all of these different things and try to move the patient forward overall.
Melanie: Explain a little bit about neuromodulation, Dr. Shaw, and how that works for people to help control their pain.
Dr. Shaw: Some of the approved indications are chronic low back and leg pain after spinal fusion surgery. A lot of times, after spinal fusion surgery somebody may continue to have low back pain or their original low back pain may be replaced with a new back pain after the surgery and they may also continue to have leg pain. Spinal cord stimulation, which is the most common type of neuromodulation is a small electrode that is placed on the epidural space floating behind the spinal cord, frequently in the area of the lower several rib, sometimes in the middle of the thoracic spine which the thoracic spine is where the ribs are, or even sometimes in the upper, depending upon which part of the body you’re trying to cover. It tends to cover up the pain with a pleasant tingling, vibration kind of sensation which the patient finds more pleasurable and pleasing than the pain. There’s a trial period which is usually four to seven days and then, if that trial is successful, hopefully, with at least 30-50% reduction in pain as well as improvement and function and reduction in pain medication, then that patient can be thought to be a successful candidate and go onto permanent implantation of the device. The leads are, therefore, then placed permanently in the spine in a place floating behind the spinal cord. The battery is placed usually in the hip or the flank under the skin. You can think about it like a pacemaker for pain. It blocks the pain signal and replaces it with a vibration or a tingling which generally allows a patient to be more functional, have a better quality of life, be more active and take less medication.
Melanie: So then, speak about biofeedback as a treatment option and a coping mechanism because a lot of the issues with pain is how much you can tolerate and being able to live that quality of life.
Dr. Shaw: Sure. Anybody listening to the program may have noticed that they have more pain when they’re stressed out or they get a headache and this is all because of the body’s response to stress. Biofeedback and different kinds of coping mechanisms, which are the psychological aspects of what we do, can really be helpful in helping to reframe and give patients alternate ways to deal with the pain rather than just taking a pill. It’s, obviously, more helpful for some patients that really understand how this is important and viable for their life and some patients just don’t understand that concept and have a difficult time really incorporating it into their lives. Nonetheless, it’s applicable and suggested for the majority of our patients and sometimes it’s very successful and you go on to have very successful reduction or elimination of pain medication with little or no other treatment other than the biofeedback or the coping mechanism. Sometimes it allows the patient to tolerate and be ready to accept the next stage of treatment, whether it be an injection or different medication or neuromodulation.
Melanie: In just the last few minutes, Dr. Shaw, please explain a little bit about the Shepherd’s Spine and Pain Institute and your multidisciplinary approach.
Dr. Shaw: Sure. We have two physicians, one nurse practitioner, four nurses, four MA’s, two psychologists and a physical therapist. We all work together as a team-oriented approach to help the patient in all of the multifaceted ways that we have just been discussing. Each person on the team has their individual role but we all work together because a lot of times, the nurses will remind me about something that maybe I hadn’t considered for a certain patient or I will remind the nurses to educate them about the TENS unit which is a skin device that can cause tingling as well. The psychologist may bring up an aspect of their life which I wasn’t aware of which could help me to focus my treatment with a different medications or send them to another specialist. We all work together. We discuss these patients on a regular basis to help and to augment different aspects of their lives to improve function and their quality of life and to maximize it to whatever extent is possible given their given condition. That’s really what a good multidisciplinary team of pain approach should include.
Melanie: Thank you so much for being with us today, Dr. Shaw. It’s great information. You’re listening to Shepherd Center Radio and for more information you can go to Shepherd.org. That’s Shepherd.org. This is Melanie Cole. Thanks so much for listening.