What if you could treat severe pain without narcotics?
The nation's opioid epidemic continues to make grim headlines as it devastates communities in Illinois and around the country. In Illinois, more people die each year of an opioid overdose, whether heroin or prescription painkillers, than of gun-related causes or car crashes, according to the Illinois Department of Public Health.
But there's reason for hope, courtesy of Chicago: a concentration of doctors and researchers who are the vanguard of a national push to treat pain without narcotics. Alternatives can't
come quickly enough, as drug overdoses in the state increased 7.6 percent from 2014 to 2015—making Illinois one of 19 states with a "statistically significant" uptick in overdose deaths, according to the Centers for Disease Control & Prevention.
"There's no doubt that alternative forms of pain management are essential to reducing opioid abuse," says Juliet Sorensen, a professor of law at Northwestern University who organized a recent symposium in Chicago on the epidemic. "But they take more time, more effort and more resources than popping a pill, which is how we got ourselves into this problem in the first place."
Concern about opioids has created a push for both the advancement of safer clinical alternatives and a better understanding of pain in general. As a result, Timothy Lubenow, an anesthesiologist and pain medicine specialist at Rush University Medical Center, tells his young medical fellows that there's never been a better time to work in the field. His Rush Pain Center has been a national leader in studying opioid alternatives including spinal cord stimulation.
For three decades Lubenow has specialized in the procedure, in which a device similar to a pacemaker is implanted under the skin. It uses mild bursts of electrical current to disrupt the pain signals that originate in the spine's nerve fibers, preventing them from reaching the brain. The replaceable devices, which last up to eight years, are a long-term treatment for chronic pain that can prevent people from remaining on prescription painkillers indefinitely. Lubenow says that while spinal cord stimulation has been FDA-approved since 1967, improvements in the devices over the past 18 months mean the electricity is better targeted and can be varied in intensity, which helps patients who have built up a tolerance.
"Stimulation is gaining greater traction because there have been a number of randomized controlled studies that show it reduces pain more than surgery," he says—especially in patients with chronic back pain. "It's an effective way to get by with a lower dose of opiates or no opiates at all."
There's a catch. Lubenow says it's a huge hassle to get insurers to approve the stimulators, which cost about $105,000. A month of opioids, by contrast, runs about $80.
One of his patients recently saw a 50 percent improvement in her nerve pain during a trial of a new stimulator. Despite the results, her insurance refused to pay for the device after the trial ended. Lubenow had to send a letter to the Illinois Department of Insurance, asking them to investigate, before the insurance money came through.
"Opioids are more economical in the short term but are an incredibly expensive drain on our economy in the long term," says Sorensen, the Northwestern professor. "That's why it's critical we move away from this short-term perspective."
UNDERSTANDING PAIN AND THE BRAIN
It's particularly critical when treating children and young adults. At Lurie Children's Hospital, doctors have reduced the use of opioids, especially in teens who undergo sports-related knee and shoulder operations. Instead, they insert catheters to deliver anesthetizing nerve blocks to the area for several days after surgery.
"We almost never use opioids exclusively and instead use a multimodal approach that is just as effective," says Dr. Santhanam Suresh, chairman of pediatric anesthesiology at Lurie and director of its pain management team. By "multimodal," he means an approach that includes nerve blocks to get patients over the hump of intense postoperative pain, combined with gabapentin, a non-narcotic seizure drug that also eases nerve pain. Plus, there's good old-fashioned ibuprofen.
Ritesh Shah, an orthopedic surgeon at the Illinois Bone & Joint Institute, has begun using a non-narcotic local anesthetic that he says allows his adult patients who get hip and knee replacements to recover more quickly and go home sooner than when treated with opioids. The painkiller, sold under the brand name Exparel and injected directly into the surgical site, offers pain relief for up to 72 hours. According to Shah, patients who receive it can get up and walk within 30 minutes of surgery, climb stairs within 60 minutes and go home after 90 minutes. Patients treated with opioids, meanwhile, stay in the hospital for several days and don't walk for 24 hours.
Shah says minimizing opioid use prevents feelings of light-headedness and fuzziness, which allows the patients to walk sooner. Walking lessens pain and prevents nausea because it helps move the bowels. "One of the best forms of pain control is early mobilization," he says. "When these patients get up and walk early on, they develop confidence and they actually have less pain."
Shah, who has no relationship with Exparel's manufacturer, Parsippany-Troy Hills, N.J.-based Pacira Pharmaceutical, says opioid painkillers are a big part of the reason traditional joint replacements require several days in the hospital. Those stays can cost between $10,000 and $20,000 and can put otherwise healthy patients at increased risk for hospital-acquired infections.
While doctors pursue opioid alternatives with patients, scientists at Chicago's research institutions, meanwhile, are trying to solve the problem on a different level, by better understanding how pain registers in the brain.
At Northwestern, scientists recently identified the region of the brain responsible for the so-called placebo effect, which explains why some people feel significant relief from fake treatments.
This is important because it will allow doctors to individualize pain therapy by choosing medication based on how a person's brain responds to a drug, says Vania Apkarian, a professor of physiology at Northwestern's Feinberg School of Medicine. This should reduce opioid use while still providing effective relief. "The placebo effect has been used as medicine for centuries without any scientific technology behind it," he says. "This study says there is a biologically based process behind it."
Ultimately, chronic pain management is an inexact science. Opioids are incredibly effective at reducing pain but should not be used for more than two or three months to avoid dependence, doctors say. Injections and spinal stimulation can work for longer-term pain, but they can lose efficacy over time.
"I think the problem is the unrealistic expectations created by the drug companies," says Khalid Malik, a professor of anesthesiology at the University of Illinois College of Medicine who runs UI Health's pain management center. "Everyone jumps on treatment bandwagons, but certain types of pain cannot be treated effectively."
In these cases, the psychological and holistic elements of pain management become critical. Hospitals are increasingly using multipronged, long-term approaches that eschew quick fixes in favor of cognitive therapy and biofeedback. The pain management groups at Rush, University of Illinois and Lurie all use psychologists to help patients develop coping skills, such as deep breathing and visualization.
Suresh, the Lurie anesthesiologist, says doctors also need to sit down with patients before surgery to minimize pain "catastrophizing." "We need to counsel patients, saying, 'You're going to be hurting, but here's what we're going to do,' " he says.