More doctors trying drug-free techniques to treat chronic pain

back pain - istockphoto - be well
back pain - istockphoto - be well
The Boston Globe

Nearly half of all Americans contend with chronic back pain, headaches, or joint discomfort at some point in their lives, yet painkillers to bring relief have recently come under increased scrutiny for their health risks.

Last month, the US Food and Drug Administration slapped new warnings on extended-release opiates, such as OxyContin and Opana ER, to make it clear that they should be used only as a last resort treatment for those in severe continuous pain; that’s because of their risks of addiction—even when used at the recommended doses—and of accidental overdose and death. Chronic use of non-steroidal anti-inflammatory painkillers like aspirin, ibuprofen and naproxen have long been known to increase the risk of ulcers and internal bleeding, but even the seemingly innocuous acetaminophen (Tylenol) has its risks.

An investigative series recently published by the non-profit group Pro-Publica noted that more than 1,500 Americans died over the past decade from liver damage due to taking an accidental overdose of Tylenol and that many of these deaths could have been prevented if the FDA lowered the maximum allowable dose of acetaminophen.

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So what’s the solution for chronic pain, and why are we so reliant on drugs to manage it?

For the past two decades, doctors have been told to consider a patient’s comfort level to be an important vital sign that should be checked along with blood pressure, pulse, and temperature at every office visit. Just like hypertension, pain, doctors believe, requires treatment—usually with drugs.

“Doctors common prescribe opiates when over-the-counter medications fail to control pain,” said Dr. Jatinder Gill, a pain management specialist at Beth Israel Deaconess Medical Center, “but now the pendulum seems to be swinging the opposite way as we learn more about their risks and potential for abuse.”

Drug overdose death rates in the United States have more than tripled since 1990 as prescriptions for opiates surged, according to the Centers for Disease Control and Prevention. In 2008, more than 36,000 people died from drug overdoses, and most of these deaths were due to prescription painkillers.

Getting patients off of popularly-prescribed opiates like Vicodin (acetaminophen and hydrocodone) or Percocet (acetaminophen and oxycodone), however, has proven to be a real problem. A study published Tuesday in the Journal of the American Medical Association found that more than three-quarters of obese patients who had chronic pain conditions alleviated by bariatric surgery remained on prescription opiates up to a year after their surgery.

Weaning patients off the drugs can be very complex and difficult for some primary care physicians to achieve especially if patients are convinced that their pain is being well managed by the drugs, said Boston Medical Center internist Dr. Daniel Alford, who wrote an editorial that accompanied the study.

“How much functional improvement and pain relief gets attributed to the medications and how much patients want to stay on them because they’ve become dependent on them is hard to determine and becomes a judgement call,” he added. “Often these factors are mixed together and that makes it so damn complicated.”

He’d like to see a stronger emphasis placed on non-medical ways to relieve pain like massage therapy, acupuncture, physical therapy, and yoga therapies. Unfortunately, most primary care physicians don’t have ways to provide those services themselves, and insurance coverage for them can be spotty.

Beth Israel Deaconess recently moved integrative medicine services into their primary care department to help facilitate the use of these services for patients experiencing chronic pain.

“I do stress management and integrative medicine evaluations,” said Dr. Aditi Nerurkar, a primary care physician and assistant medical director at the hospital’s Cheng & Tsui Center for Integrative Care. “I see patients who have everything from back pain to migraines and can send them next door to our acupuncturist or teach them meditation techniques myself.”

Getting insurance coverage for all these services can be tough. As a doctor, Nerurkar said her evaluations and meditation counseling are often covered, while patients often have to pay out of pocket for yoga classes or acupuncture administered by non-physicians.

And unlike drugs, which have been tested to determine a safe and efficacious dose, doctors still haven’t determined how much massage therapy or acupuncture a patient needs for pain relief. “Likely the ideal dose needs to be individualized to the particular patient, but it’s a hot research topic right now,” Nerurkar said.