Last year, OutreachNC Magazine published a four-part series exploring the opioid crisis from many different perspectives including how it affects communities, families, and individuals. We reached out to Pinehurst Surgical’s Dr. Lynn Fraser, who specializes in pain management, to better understand opioid use for pain management including myths about opioid use, alternatives for pain management, and transitioning from opioid-based pain management to other methods.
We are grateful for Dr. Fraser’s insight into this important issue.
ONC: How does regular opioid use for pain turn into addiction? Is there a tipping point, so to speak (a time frame or dosage) that is a marker for people to indicate addiction may be on the horizon?
LF: There is no specific time frame or dosage that is indicative of addiction. However, concerning behaviors include taking the medication more frequently than is prescribed or at a higher dosage than is prescribed and/or experiencing cravings for the medication.
Physicians use a risk assessment tool to indicate the likelihood of opioid abuse. A combination of the following indicates a patient that might be at higher risk: family or personal history of alcohol or drug abuse, age less than 45, history of preadolescent sexual abuse, and psychiatric diseases, including depression.
ONC: What is the biggest misconception about opioid use in the aging population?
LF: The biggest misconception in the aging population is the fear of addiction. While this is certainly a concern, studies have shown that older age is associated with a much lower risk of opioid abuse, estimated to be as little as 3% of patients over age 65 that are prescribed opioid medications for non-cancer pain.
ONC: What is the biggest myth about opioid use for pain management?
LF: The biggest myth is that opioids are that the mainstay treatment for chronic pain (defined as pain lasting >3 months). In fact, current CDC guidelines include opioid medications as a “non-preferred,” meaning not first-line, therapy for chronic pain. It is important to note that this does not include cancer treatment, palliative, and end-of-life care, in which cases opioid medications are in fact used, generally in a more liberal manner.
ONC: How can a patient begin a conversation with his/her healthcare provider about opioid use? Is this a conversation to have before opioid use begins or only if a ‘problem’ emerges? If a patient is referred, for example, to pain management, does the patient need to discuss opioid use with his surgeon, family care doctor, or the pain management doctor?
LF: Patients can ask their healthcare provider if opioid medications are appropriate to incorporate as part of their treatment plan. If they are already taking opioid medications and would like to make a change, patients can ask if they are candidates for alternative therapies to use in conjunction with or instead of their current medications. It is important to incorporate all healthcare providers providing care for patients in the decision-making process as far as opioid medications.
ONC: Can you provide examples of alternatives to opioids for long-term pain management?
LF: The mainstays of pain management include medications, physical therapy, and/or interventional management. There are many medication alternatives to opioids; for example, neuropathies (medications that work at the level of the nerve), non-steroidal anti-inflammatories, muscle relaxants, and anti-depressant medications are used alone or in combination to manage pain long-term. Physical therapy is another option that can help patients, especially if the exercises are continued at home. Interventional management, injecting steroid into the area of inflammation under x-ray guidance, can be incredibly efficacious in relieving pain as well, which is the focus of my practice.
ONC: What are the biggest impediments for people seeking alternative therapies? Is insurance an issue? Is a lack of information an issue? Do doctors themselves lack knowledge of these alternatives, thereby limiting the discussion with patients? Are patients reluctant to try alternative therapies for fear of being in pain or lacking results?
LF: We have excellent results in insurance coverage for the above-outlined therapies. However, insurance typically does not cover therapy such as massage, acupuncture, and investigational medications like ketamine infusions and CBD oil.
Most physicians are well-versed in alternative therapies, especially in recent years with stricter guidelines surfacing about the prescribing of opioid medications. In fact, it is commonplace for surgeons to implement alternative therapies as part of their operative protocol.
Patients can in fact be hesitant to try alternatives for fear that these treatments will not relieve their pain. Neuropathic agents are not medications that you take and feel a reduction in pain some minutes later, as with opioid medications. They impart their effect at the nerve terminal slowly, over time; many patients do not realize how much these medications are actually helping them until they discontinue them.
ONC: What role do family members and loved ones play in helping someone transition from opioid-based pain management to alternative therapies?
LF: The best way a family member can support their loved one is to maintain an optimistic attitude and to provide encouragement. It is important to keep in mind that there is usually not a “magic bullet” that will help 100% of the pain. Often, long-term pain management looks closer to a piecemeal approach. For example, a medication may help 20%, additional medication may provide another 30% of relief, physical activity may provide a 20% reduction in pain, and social support can often provide the last bit of improvement. The impact of strong social support in a patient’s prognosis is often underestimated and has been shown to be instrumental in recovery and healing.
ONC: How do opioids impact older adults differently than younger adults? Do we metabolize medication differently? Do our bodies respond differently?
There are certain considerations in opioid metabolism as part of the normal aging process. Alterations in the GI tract decreased blood flow to the liver and kidneys, and reduced muscle mass can all result in opioid medications being more potent, and having a longer duration of action than predicted. Other considerations include polypharmacy and medical comorbidities, meaning an older patient is more likely to be on several medications and to have other medical diagnoses, all of which must be taken into account when prescribing medications.
ONC: Are clinical trials available for alternative therapies in pain management? Is this something people in chronic pain might consider?
LF: This is certainly a consideration, as a treatment for pain is highly investigational in nature and constantly evolving. Clinicaltrials.gov is a website with the most up-to-date information about trials that are now enrolling.
ONC: What are the biggest side effects of opioid use that might be reduced by using alternative therapies for pain management?
LF: The most commonly reported side effect from opioid medications is constipation, which can be severe and unresponsive to standard laxative medications. This side effect typically resolves after the medication is discontinued. Depressed mood is another common side effect seen with opioid medications, especially with long-term use. Perhaps the most feared side effect from opioids is respiratory depression, which is not a concern with alternative therapies.