Managing Chronic Pain Admidst the Opioid Crisis

The fact that the country is currently in the midst of an opioid abuse crisis doesn’t negate the reality that people are still living with chronic pain that deserves to be treated. When used appropriately and conservatively in the correct population of patients, opioids remain a valuable tool to alleviate chronic pain. While physicians are now more aware of the pitfalls of prescribing short and long term opioids, the discussion and use of other pain management modalities needs to be highlighted and appreciated more than ever.

The explanations of “you’re just getting old” or “just live with it” when patients ask their doctors for pain management options, are still unacceptable in my opinion. My fellowship training in Interventional Pain Medicine at the Cleveland Clinic Hospital not only taught me when to and when not to use opioids but also to integrate procedures, therapeutic injections and minor surgery into the treatment plan. It is important to devise a plan that considers the individual and caters to their needs, lifestyle and personality.

Two extremely useful procedures that I perform for the treatment of low back pain are the MILD, Minimally Invasive Lumbar Decompression, and Spinal Cord Stimulator (SCS). The MILD procedure is a great option for patients who have been diagnosed with low back pain due to Lumbar stenosis. Lumbar stenosis is narrowing of the spinal canal. It is a degenerative condition, basically arthritis of the spine, which may occur as we age. It causes pain in the low back that is exacerbated with standing and walking. The typical person with this problem needs to sit down or lean forward after a period of time in order to relieve the pain. Eventually, the ability to walk distances or stand for a prolonged of time diminishes to the point that the person is mostly sedentary.

Previously, the options to treat this type of pain have been epidural steroid injections or surgery. Steroid injections are beneficial and still considered a first line treatment option, however, may not provide the prolonged relief that one needs. They are also dose limited, meaning that once the maximum dose has been reached, they can’t be repeated until after a certain “rest period” despite ongoing pain. Surgery has increased risks and many people are not healthy enough to tolerate or recover from it. The MILD procedure is a one hour outpatient procedure that widens the spinal canal by gently removing excess bone and ligament. It is a safe procedure, no anesthesia needed, no stitches and low complication risk. Clinical studies proved 79% of patients had positive outcomes with increased standing time from 8 to 56 minutes, walking distance from 246 feet to 3,956 feet, and 53% pain reduction.

The SCS is an outpatient procedure that is essentially a pacemaker for the spine. It has been used for decades to treat multiple causes of severe pain by blocking the pain signal at the spinal cord. The most common use is for chronic back and/or leg pain due to stenosis or nerve injury. It is a minor outpatient surgical implant procedure that is an option for people who have failed to obtain relief with conservative treatments, medications, injections and surgery. The advantage of this treatment option is that the patient does a temporary “test drive” of it in order to determine if it will successfully alleviate the pain and increase the level of function. The goal is to reduce the pain by at least 50% and increase function at least 50% to proceed to permanent implantation. The “test drive” is called a trial or screening procedure that is not a surgery and allows the patient to experience the benefits of SCS for one week in order to make the best decision about pursuing the option long term.

Individuals who have been using opioids carefully and responsibly under the guidance of their physician are worried that the medication that has been allowing them to function with a tolerable amount of pain will be discontinued due to the crisis. The effect of disallowing use despite the individual circumstance could be devastating for many. It is important to be mindful about when, why, and how much of an opioid analgesic is being prescribed, but the medications continue to have a legitimate role in a chronic pain treatment plan for appropriate patients. The amount of opioids needed to control pain may be reduced or eliminated by also using interventional modalities such as those discussed above.