Pain Specialist Doctor Discusses Different Ways To Treat Chronic Pain

Mar 9, 2018
Originally published on March 9, 2018 7:03 pm

In light of a new study that finds non-opioid painkillers are just as effective as opioids in treating certain types of chronic pain, Dr. Ajay Wasan, professor and vice chair for pain medicine at the University of Pittsburgh Medical Center, answers questions from listeners about opioids and chronic pain.

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ARI SHAPIRO, HOST:

Opioids affect millions of Americans today whether people use them to manage pain, struggle with addiction or know someone who has died from an overdose. Today we're going to try to answer some of your questions about opioids and chronic pain specifically. We're focusing on chronic pain because of a new report out this week in the Journal of the American Medical Association. It found that non-opioid painkillers like acetaminophen and ibuprofen were as effective as opioids at treating chronic back, hip and knee pain with fewer side effects.

Earlier this week, we asked for your questions about this. And for answers we have called up Dr. Ajay Wasan, a pain specialist at the University of Pittsburgh Medical Center. Hi there.

AJAY WASAN: Hi.

SHAPIRO: I want to start with a question from Emma Juneau, who wonders about the safety of acetaminophen, or Tylenol, as an alternative to opioids. She asks, isn't it true that acetaminophen can be very damaging to the liver, particularly with daily long-term use? Does she have a point there?

WASAN: There is something there. So for treatment of chronic pain, especially for arthritis pain, higher doses of acetaminophen - so two Extra Strength Tylenol twice or three times a day - has been recommended, and there are good studies supporting that. But that can be associated in some people with some rise in their liver enzymes. It would be very rare for those slight rise in the liver enzymes to get to a state of toxicity where the liver is actually damaged. The trouble is we don't know what percent of people get that little rise. What's the chances that a slight, you know, increase in liver enzymes are going to lead to liver damage? But there is something there, as your caller mentioned - both non-opioids and opioids do have side effects.

SHAPIRO: We have a question here from Rachel Esser in Tampa, Fla. And she sent us a voice memo.

RACHEL ESSER: I recently started wondering why acupuncture isn't a part of the discussion as an alternative for opioids. It seems like a simple, non-invasive alternative to painkillers, but most insurance plans don't cover it for this purpose. Is there any work being done to evaluate its effectiveness?

SHAPIRO: Dr. Wasan, what do you think?

WASAN: Yes. So there's a lot of research going on to - about its effectiveness and the mechanisms for acupuncture. So the literature suggests and the studies suggest that for chronic low back pain and chronic knee arthritis pain acupuncture can be effective. And just like many of our treatments for chronic pain, it tends to be a subset of people. Approximately 20 to 30 percent will get significant improvement with acupuncture. And it's a good point as to why it's not better covered because many of our pain treatments for chronic pain really confer significant improvement in only 20 or 30 percent. We often have to try different things and combine different treatments together. The term that we use is multimodal pain treatment.

SHAPIRO: On the subject of insurance coverage, another listener asks why physical therapy, which has shown to help ease pain, is so much more expensive than an opioid prescription. What role are insurance companies playing here in steering people to one form of pain management or another?

WASAN: This is a wonderful point that is such a vexing issue for any provider who takes care of chronic pain, which is that some of the treatments that have been proven more effective and safer and have better long-term outcomes such as physical therapy may have a 20 to $40 copay for each visit versus an opioid, which could easily just have a $5 copay for an entire month's supply. So it's a huge problem that insurance companies need to contend with across the country and realize that there are all sorts of hidden additional costs with prescribing an opioid. And in the long run, it may be that using many of these non-opioid approaches - you know, physical therapy, other non-opioid medications - really provide the best improvement in chronic pain but also lower costs.

SHAPIRO: We got so many questions about alternatives to opioids, whether acetaminophen or acupuncture or physical therapy, and several people asked us about medical marijuana. Gary Price in Colorado wrote in to say that he used to take up to three Percocets a day for pain related to surgeries and injuries, but a couple of years ago his doctor told him he was being pressured to stop prescribing opioids for chronic pain, so he switched to medical marijuana and says it's working fine. How widely is this being discussed?

WASAN: Very widely. It's a really hot topic in the field of chronic pain treatment. And when you look at all the different studies, you see some of the same patterns for the effectiveness of medical marijuana as you see for a lot of our other chronic pain treatments. And so for neuropathic pain, which is pain related to nerve damage or related to the nerves not functioning properly, there's some evidence for medical marijuana, meaning that some patients do respond and do get better. But it's only about 20 to 30 percent on average. And it's amazing how that figure creeps up for, oh, so many of the chronic pain treatments we have. Twenty to 30 percent on average will get a significant positive response.

And then the other point - can you use medical marijuana instead of opioids? And so there's very little data on that, but that's an area that, you know, many pain specialists and others are exploring, which is, you know, if it's reasonable to - the term is often you certify someone for medical marijuana. Can you use that as a way of decreasing or avoiding opioids?

SHAPIRO: We've been talking about chronic pain, but I also want to play you a question about prescribing opioids after surgery. Linda in North Carolina asked that we not use her last name to protect her family's privacy. She says after her husband had surgery, the discharged doctor wrote him a 30-day opioid prescription.

LINDA: When I asked her, why are you prescribing 30, she said, well, that's just how it's done. I was pretty shocked by this. I'm wondering what kind of education or policies or procedures are being put into place for discharging physicians and others.

SHAPIRO: That's just how it's done. Dr. Wasan, is that how it's supposed to be done?

WASAN: No, it's not how it's supposed to be done. There's been a number of wonderful studies that have come out in the past 10 years looking exactly at this issue and trying to get at this idea of, what is the optimal amount of time after surgery someone should be prescribed opioids for? And it may vary by surgery. And this is an issue that many, many health care systems, and including ours here, are really tackling to avoid prolonged opioid use after surgery.

SHAPIRO: One concern that a lot of people expressed is that they use opioids to manage pain and people make them feel like they're a bad person. Medical personnel look at them suspiciously. Barbara Huffman of Lawrenceville, Ga., asked, am I wrong to want to continue taking the drug that alleviates my torturous pain?

WASAN: And that's so important. And we see that so much as pain specialists. The patients who have been on appropriate doses of opioids for appropriate time and doing very well - maintaining their function, doing all sorts of things, having good pain control - do get stigmatized. And that's an important negative consequence that's happened of the opioid epidemic and the increased scrutiny. You know, as the message goes out that opioids are not good, unfortunately get painted with a very broad brush that opiates are not good for anybody. And that's simply not the case.

SHAPIRO: We heard from so many people who have just terrible, unrelenting pain whether it's from a car crash or fibromyalgia or other diseases. They've tried non-opioid medications and acupuncture and physical therapy, and opioids are the only thing that has given them relief. Helen Stevens, who has taken prescription opioids for 15 years, says, we the patients are terrified of being swept up in the storm of opiate rejection and having our medicines taken away from us. Dr. Wasan, do you think that fear is justified?

WASAN: Absolutely. Helen really hit a very important issue right on the head, which is, what do you do if the non-opioids do not work? Is it reasonable to put people on opioids? And there is literature that suggests that, yes, that is the case. And it's all about this issue of responders and non-responders. You know, when you read studies, they average everyone together. So some people do well on opioids and some people do poorly. But there's always a spread. And that's a key thing that's missing from, I think, the debate and the controversy in the country, is that there are responders and non-responders. And we need to do a better job of identifying them and also spreading that word that there are people like Helen who can do well for many years without having any problems with addiction or abuse.

SHAPIRO: Dr. Wasan, thanks for answering these listener questions for us today.

WASAN: Thank you.

SHAPIRO: Dr. Ajay Wasan is professor and vice chair for pain medicine at the University of Pittsburgh Medical Center.

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