Issue 9 Stories
Feature

Managing Pain Without Opioids

Sentara RMH Physician Offers Patients Helpful Alternatives

The back pain Roger Lam was experiencing following radiation treatments for colon cancer became so unbearable that it landed him in the Sentara RMH Medical Center Emergency Department. 

“The pain got to the point where, when I was doing work around the house, I couldn’t get up and down, and I was having trouble just moving around,” recalls Lam, 76, of Elkton, who was treated for colon cancer four years ago. 

In search of a plan for long-term pain relief, Lam turned to the physicians at Sentara Back & Neck Specialists. One factor that was important to Lam and his physicians was managing the pain without the use of opioid medications. 

“I’m not too crazy about taking opioids,” says Lam. “They’re hard to deal with, and I also worried about getting hooked on them.” 

Fortunately for Lam and patients like him, numerous pain relief options are available. According to C. Joel Hess, MD, a Sentara RMH pain management physician with Sentara Back & Neck Specialists, pain-relief techniques and medications that do not rely on opioid use include the following: 

• Neuropathic medications (to calm irritated nerves—for example, Cymbalta) 

• Anti-inflammatory medications (such as ibuprofen, naproxen and prednisone) 

• Muscle relaxants (to relieve muscle spasms) 

• Epidural injections (to help relieve inflamed nerves in the spine) 

• Radiofrequency neurolysis (in which radio waves are used to decrease pain signals from spine arthritis) 

• Facet injections (in spine joints that allow the back to bend) 

• Sacroiliac (pelvic) joint injections 

• Spinal cord stimulation (in which a device is implanted within the spine to block pain signals) 

• Physical therapy (to strengthen, stabilize and improve flexibility) 

After consulting with Dr. Hess, Lam has found relief through a combination of anti-inflammatory medications, intermittent epidurals, neuropathic pain medication and physical therapy. According to Lam, the physical therapy really helped. 

“We did light stretching of my lower back around the hips and in those areas where I was tight,” Lam says. “I could definitely tell it made a difference.” 

The Current Opioid Crisis 

Opioids, sometimes referred to as narcotics, are a class of drugs used to reduce pain. They include the following: 

• Prescription medications such as oxycodone (OxyContin), hydrocodone (Vicodin), morphine and methadone

• Fentanyl, a synthetic opioid pain reliever that is significantly more potent than morphine. Physicians prescribe it to treat severe pain—typically advanced cancer pain—but it’s also manufactured and distributed illegally. 

• Heroin, an illegal opioid. 

Unfortunately, opioid medications were overprescribed for decades, and now physicians, lawmakers and patients are coping with the aftermath. (See the sidebar, Common Questions About Opioids.) 

According to the Centers for Disease Control (CDC), more than 60,000 drug overdose deaths occurred in the United States in 2016, the most recent year for which statistics have been analyzed. Opioids, both prescription and illicit, were responsible for 66.4 percent of those overdose deaths in 2016.

In Virginia, 507 people died in 2017 due to prescription opioid misuse, and 938 people due to fentanyl and/or heroin overdose, according to the Virginia Department of Health. Those numbers were both increased from 2016. 

How Are Opioid Medications Used? 

Opioids primarily work in the brain stem to suppress the transmission of pain signals. However, they can also create feelings of euphoria, and over time people can develop a tolerance to opioids and become addicted, which was one of Lam’s major concerns with taking them. 

Genetic, psychological and environmental factors all play a role in determining the risk of addiction and abuse, according to Dr. Hess. He points out, however, that in some cases opioids are appropriate. Physicians commonly prescribe them for cancer care and end-of-life palliative care, as well as in acute situations, such as after surgery or to relieve the pain of a severe injury. Challenges tend to arise with long-term use. 

“We’re becoming much more judicious about whom we give opioids to, particularly on a long-term basis,” says Dr. Hess. “There’s a lot of data showing that opioids can treat pain effectively in the acute period, but there are certainly better options for long-term pain management.” 

Prescription Guidelines 

To better regulate how physicians prescribe opioids, the Virginia Board of Medicine specifies that for acute nonsurgical pain, a patient should not receive an opioid prescription for more than seven days, unless extenuating circumstances are clearly documented. 

For postoperative pain, a prescription typically should not exceed 14 days. Following major surgeries or injuries, however, some patients may need to take them for longer, according to Dr. Hess. 

Due to recent media attention on the opioid crisis, he has found that many of his patients are well aware of the medications’ potential risks. 

“There are times when a patient is so fearful of overdose, because of what he or she has heard in the news, that I actually have to convince him or her that it’s OK to take the medication,” he says. “There are certainly situations with severe, acute pain—such as with a spinal fracture—when opioids are the best option.” 

A Mix of Treatments for Best Results 

For Steve Thompson, 66, of Luray, back pain from degenerative discs was causing increasing pain. In time, over-the-counter pain medications became less effective in providing relief, and he needed other alternatives. 

“I had trouble walking,” says Thompson. “I was limited in what I could do, and I couldn’t stand up straight.” 

After retiring as a supervisor for a distribution center, Thompson started a second career in the public works department for the town of Stanley—a physically demanding job that sometimes requires lifting and digging. He is also a volunteer firefighter in Luray. Since his condition was having such a negative impact on his daily activities, he turned to Dr. Hess for a plan to treat his back and shoulder pain. 

His treatment has included steroid injections in his shoulder and steroid epidural injections for his back. He also takes nonsteroidal anti-inflammatory medications, medications specific for nerve pain, and occasionally hydrocodone. 

Like Lam, Thompson also has battled cancer. After he began experiencing frustrating sciatic pain, Dr. Hess ordered an MRI that revealed a tumor to be the source of the problem. Dr. Hess and Thompson’s oncologists worked together to craft a treatment plan. 

“Medicine is certainly both an art and a science, and finding the specific regimen to fit a patient’s needs can be challenging at times,” says Dr. Hess, “but we have many ways to fight pain.” 

What’s Next? 

When government oversight agencies began putting limits on opioid prescriptions, they started working closely with patients and doctors to raise awareness of opioid misuse issues and advise on the use of other available pain management options. Since then, state medical boards, the CDC, the National Institutes of Health (NIH) and local government entities all have contributed to patient and physician education. 

In April 2018, the NIH launched the HEAL (Helping to End Addiction Long-TermSM) Initiative, an aggressive campaign across various agencies to find speedy solutions to stem the national opioid public health crisis. 

Goals of the initiative include improving treatment for opioid misuse and addiction, as well as enhancing pain management for the more than 25 million Americans who suffer with chronic pain. These efforts include a clinical trials network for testing new pain therapies. 

The wide range of pain management options available to patients can make a drastic difference in their quality of life. Lam is thankful that he doesn’t have to rely on opioid medications to relieve his chronic pain. 

“I’ve been very pleased with the results I’ve achieved, working with Dr. Hess and the physical therapists at Sentara RMH,” he says. 

Thompson adds that he’s grateful to have the opportunity to work in his second career with public works. He enjoys the camaraderie and the chance to learn new skills. 

“It’s great at my age to be able to learn something new every day,” he says. 

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