Anesthesiologist helps craft federal guidelines for alternatives
By Charlie Jolie
Drug overdoses caused a record 47,055 deaths in the U.S. in 2014, making them the leading cause of unintentional death for Americans that year, according to the U.S. Centers for Disease Control and Prevention. By comparison, these deaths were 1.5 times more than the number of people killed in car crashes the same year, nearly flipping the order in 1999, when there were more than twice as many motor vehicle deaths as fatal drug overdoses.
This alarming trend is driven by a legal drug — opioid painkillers — which has prompted a growing outcry among government officials and health care professionals to limit the amount of opioids a physician can prescribe. However, pain management expert Asokumar Buvanendran, MD, says blaming the over-prescription of opioid painkillers is an oversimplification.
The director of orthopedic anesthesia and a professor of anesthesiology at Rush, Buvanendran says that truly addressing the epidemic of opioid addiction must begin with making primary care physicians aware that safe and effective pain management alternatives to opioids exist. He has been helping the CDC to do just that as one of 18 pain management experts on the CDC Stakeholder Review Group that helped inform the CDC's Guideline for Prescribing Opioids for Chronic Pain released on March 16, 2016.
A prescription that has become a problem
Opioids work by attaching to certain proteins, called opioid receptors, that are located mainly in the brain and spinal cord. Opioids cause the brain to send pain blocking signals through the body, but they also cause dependence, and slow breathing.
As a result, opioid painkillers are involved in 61 percent of all drug overdose deaths and are the first pain-killing drug abused by those who use heroin, according to the CDC. Reflecting the epidemic of opioid painkiller misuse, the amount of prescription painkillers dispensed in the U.S. has quadrupled since 1999, even though there’s been no overall change in the amount of pain that Americans reported to physicians since then.
The vice chairman of the American Society of Anesthesiologists’ Committee on Pain Medicine, Buvanendran says this effort is an important step in reversing the opioid epidemic, particularly because the attention focused on the CDC response can help make people aware that opioids aren’t the only pain management option. “I applaud the CDC for being a strong and active voice not just in calling attention to the problem of opioid abuse, but especially in its commitment to issue actionable guidelines for physicians that incorporate the expertise and concerns of pain management specialists,” he says.
Not that Buvanendran is calling for an end to opioid use altogether. “Used appropriately, opioids are an important tool in treating pain,” he says. “But there are very many safe, non-pharmacological and non-opioid pharmacological therapies proven to be as or more effective than opioids that don’t carry the risk of dependence.”
Three major steps to reduce opioid dependence
On behalf of ASA, Buvanendran recommended the CDC take several actions to make physicians aware of alternative therapies and make those therapies more widely available, including:
- Make prescribing physicians aware of opioid alternatives: Buvanendran says that the CDC guidelines should list specific examples of medications that are not opioid-based and non-pharmacological approaches – such as interventional pain procedures — so that prescribing primary care physicians better understand the range of alternatives. It is vital that providers only consider adding opioid therapy if expected benefits for both pain and function outweigh risks to the patient,” he says, “Understanding that there are alternatives to opioids greatly informs that consideration.”
- Clearly convey the safety and effectiveness of the alternatives: “It is important that these guidelines convey what we show at Rush every day: Non-opioid alternatives are not only effective, they are proven to be safe,” Buvanendran says. The Rush Pain Center has been a national leader in developing and proving the safety and effectiveness of non-opioid alternatives such as epidural injections, radiofrequency denervation and spinal cord stimulation. These treatments directly address and block pain where it occurs, unlike opioid painkillers, which affect the entire body.In fact, randomized controlled landmark clinical trials that demonstrated the success of non-opioid approaches were conducted at Rush University Medical Center.
- Insurance companies should cover alternatives: A fundamental barrier to many physicians utilizing non-opioid pain treatments is the fact that insurance companies often will not cover these procedures. Opioids are relatively inexpensive and insurance protocols often dictate that the lowest cost therapy be prescribed. However, the Stakeholder Review Group recommended that the CDC use its influence to encourage insurance companies to pay for these alternatives.
“It has become obvious to many today that the full cost of opioids cannot be just measured by their price,” Buvanendran says. “When you consider the societal costs, or even the longer term impact on each patient, alternatives that might be more expensive initially can be exponentially less expensive in the long run.”
Rush offers, pioneers, pain treatment alternatives
Long before the over-use of opioids was seen as an epidemic, the Rush Pain Center provided — and often innovated — a wide a range of diagnostic and therapeutic approaches. “We look past just the type or location of a person’s pain to attempt to see the whole person and what is causing their pain,” says Timothy Lubenow, MD, medical director of the pain center and professor of anesthesiology at Rush.
“We then integrate traditional medical fields such as anesthesiology, internal medicine, psychology and pharmacology with alternative medical techniques and advanced interventional pain medicine therapies,” Lubenow continues. “Our goal isn’t just to alleviate the pain, but eliminate or control it so that people can resume an active life.”
Rush pain medicine specialists offer advanced interventional pain techniques such as the following:
- Spinal cord stimulation, which are precisely delivered, mild electrical signals to the spine that block pain transmission and typically can be performed with no surgical incision
- Biofeedback, a technique to help patients control the body’s reaction to pain or other stressors. Biofeedback uses electrical sensors to provide a person with feedback about activity in his or her muscles and nerves. This feedback can help the person learn to relax certain muscles in response.
- Radiofrequency ablation, the use of high-frequency electrical currents to remove tissue from an area of the body. Doctors use it to treat a variety of conditions, including varicose veins, atrial fibrillation, Barrett's esophagus and some cancers.
- Trigger point injections, which relieve areas of muscle that have become tight and inflamed.