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Alternatives to Narcotics in Pain Control

If you suffer from chronic pain, you should know that there are many effective treatment options for chronic pain that do not necessarily involve opioids.

Dr. Wasik Ashraf discusses alternatives to narcotics in pain control, and the treatment options available at St. Luke's Cornwall Hospital.
Alternatives to Narcotics in Pain Control
Wasik Ashraf, DO
After graduating summa cum laude with a degree in biology from the New York Institute of Technology in Old Westbury, New York, Dr. Wasik  Ashraf went on to receive his medical degree from the New York College of Osteopathic Medicine, also in Old Westbury. He then trained in Orthopaedic Surgery at North Shore University Hospital in Plainview, New York, and recently completed a sports medicine fellowship at the Hughston Foundation in Columbus, Georgia. Before becoming a surgeon, Dr. Ashraf was a licensed emergency medical technician who worked as a volunteer and participated in community education programs. Dr. Ashraf has a passion for sports medicine and research. He has provided team coverage for the Roslyn, Manhasset, and Hewlett, New York high school football teams, and during his Hughston Sports Medicine Fellowship at the Hughston Foundation took care of team coverage for the Columbus Cottonmouth professional hockey team. Dr. Ashraf is currently board eligible in orthopaedic surgery and is a member of the American Orthopaedic Society of Sports Medicine (AOSSM) and the American Osteopathic Academy of Orthopaedics (AOAO) as well as Arthroscopy Association of North America (AANA).

Learn more about Wasik Ashraf, DO

Melanie Cole (Host): If you suffer from chronic pain, you should know that there are many effective treatment options for chronic pain that don’t necessarily involve opioids. My guest today is Dr. Wasik Ashraf. He’s an orthopedic surgery at St. Luke’s Cornwall’s Hospital Center for Total Joint Replacement. Dr. Ashraf, let’s start with identifying the basic types of pain. What is chronic pain versus acute pain, and since they’re somewhat subjective, how do you measure them?

Dr. Wasik Ashraf (Guest): Thank you for having me on the show, and that’s a difficult question to answer because pain is subjective and by subjective it’s something that I can’t feel for my patient. The patient has to describe it and it’s something that you have to be open to and kind of see the patient and assess how much pain they’re in and it’s very difficult to tell that from a pain scale from zero to ten and it’s a difficult way to assess. So acute pain, in my mind, acute pain is something is traumatic, something happened recently and is a surge in pain. It could be postsurgical pain; it could be from a traumatic pain. So acute pain is something that’s within the first few hours to few weeks of an injury. Chronic pain that is something that has been going over, and my – the definition that I use is over three months, where you’ve had pain in an area for over three months, you have tried different anti-inflammatory, different methods to control the pain and it’s not getting better.

Melanie: So let’s talk about opioids then. There’s an epidemic in this country. People are hearing all about it. Tell us what opioids are. What are they used for and why is this becoming such an epidemic?

Dr. Ashraf: So, there’s over 70 million surgical patients in the US per year, and as an orthopedic surgeon, we’re the third largest prescribers of opioids. The way I describe it is I cause pain when I do surgery and we want to do no harm, so it’s something that started years and years ago where someone has pain after surgery and you decrease the pain by giving them an opioid or a pain killer. Four out of five heroin users started by misusing prescription pain killers. So pain killers being out in the street, given by doctors for pain, ends up being misused. So I think the reason why there’s a huge opioid crisis in the US is we have too many pain killers on the street and the pain killers get into the wrong hands. Shows like this and discussions like this helps us to address the clinical, the societal, the economic burdens that opioid usage causes in our society today.

Melanie: So how do you work with a patient. Discuss your multifaceted approach to painful disorders. What are the first things you do when someone comes into you with pain and what if they ask you for some kind of a narcotic or opioid; what are some of the best practices that you can use for short term or long term chronic pain that are not necessarily opioid related.

Dr. Ashraf: Great, so I think the biggest thing that any physician or provider can do is discussion and communication with the patient. Every patient is different and you have to approach every patient differently. It’s kind of taboo to talk about pain outright, but that’s in my opinion the best way to start the discussion is, hey let’s have a discussion about the pain expectations, what you can expect after surgery, what I will be providing you, so there’s not an expectation that there will be an endless supply of narcotics after surgery. So first and foremost is an open discussion with the patient. Most of the time, if you say hey, these are the rules, these are the medications you’re going to get, and after this many pills you’re not going to get anymore, patients understand and they know that this is what I have to work with, and that to me has been the best thing. There’s really a multimodal approach, meaning different ways we attack pain. Give you an example from a joint replacement surgeon, as a joint replacement surgeon, what we have found is if we treat the pain before we do the knee replacement, meaning medications before the surgery, we notice that after the surgery patients take less pain medication. So what we do is we given anti-inflammatory, a small narcotic, and even a small muscle relaxant before the surgery, so that after the surgery we can quantify that the patients are requiring less medication. During the time of surgery, the type of anesthesia matters as well. Instead of using general anesthesia where we are putting a tube down someone’s throat, we use a thing called a spinal or a regional block where we numb up the nerves around the area of surgery so post surgically the area is numb and they’re not having any pain, they’re using less narcotics. During the time of surgery as well, we use medications that are local lidocaine, but there’s a newer medication that stays in the fat, a numbing medication, and the pain medication works for the first 96 hours. If we can decrease the opioid usage for 96 hours post surgically, we have found that we can cut down the use of narcotics by 80%. So where I used to give 40 tablets after knee replacement, now I give 10. It’s really a huge difference. Post surgically we get them mobilized right after surgery and we give both short term and long acting medications to decrease inflammation and pain and using that multimodal approach, we have cut down our narcotic use by almost 80% at St. Luke’s.

Melanie: Wow, and what do you think about some of the other modalities such as exercise programs, physical therapy, even meditation, yoga, you know some of these kinds of things to deal with some of these pains. People look at chondroitin, they look at supplements, and they’re not sure what to make of it all.

Dr. Ashraf: You know the scientist in me, I look at articles about things like acupuncture, chiropractic, yoga, and there’s really no great literature out there, but I will tell you I have many, many patients that swear by acupuncture. They say, hey listen when I did this my pain went down. I think there is definitely, definitely evidence that it works. So aqua therapy, yoga, Pilates, acupuncture, chiropractic and even the use of cupping techniques to decrease inflammation and pain, I think they’re all great. So I think that’s all part of a tool box that we can use to decrease someone’s pain. I think one thing to remember is that not everything will work for every one person. I think you should try to see what works. Cryotherapy, using ice as an anti-inflammatory, and even now they’re talking about cold laser, using that preoperatively and postoperatively to numb down the nerves that can cause pain has shown great evidence that it can work and multimodal approach, different types of approach to decrease opioid use I think is the wave of the future.

Melanie: I think so too, what a wonderful segment. You’ve explained it all so very well. So wrap it up for us with your best advice to patients regarding opioid use and the alternatives to narcotics in pain control, some things that they can do, and really your best advice about managing that pain.

Dr. Ashraf: So my advice for patients, individuals that say need surgery and they’re worried about opioid use. Opioid use is not going to get you in trouble. It’s opioid abuse. So there will be expectations that there will be some pain after surgery and a little bit of pain is normal after surgery. You should research the doctor, physician, or surgeon and have an open discussion with the surgeon beforehand, say hey I’m having surgery, I’m going to be in pain, what is the game plan? I think having a great game plan before the pain kicks in is the biggest advice and the best advice I can give is having a frank discussion with the surgeon and what is the plan. And once you know the plan of what the expectations are, usually things go as to plan. Research, ask your doctor about different multimodal approaches, what they use, what works for them and I think that’s to me the biggest advice.

Melanie: Thank you so very much Dr. Ashraf for being with us today and sharing your expertise in such a huge topic and that’s so important to so many people that are suffering from pain disorders and they’re not sure where to turn or what to do. Thank you again for joining us. This is DocTalk presented by St. Luke’s Cornwall Hospital. For more information, please visit, that’s I’m Melanie Cole. Thanks so much for tuning in.