A new study by researchers at The University of Texas at Dallas, UT MD Anderson Cancer Center, UT Health Science Center at Houston and Baylor College of Medicine has produced evidence of the source of chronic pain in humans, revealing several new targets for pain treatment.
The paper — published March 19 in Brain, one of the world’s oldest neurology journals — examined specialized nerve cells clustered near the base of the spine. Researchers took advantage of an exceedingly rare opportunity to study these nerves, called dorsal root ganglia (DRG), removed from cancer patients undergoing surgery at MD Anderson.
The researchers cataloged variations in RNA expression in the dorsal root ganglia cells of patients differing by pain state and sex. Using RNA sequencing, a specialized form of gene sequencing, on those DRG cells yielded a list of promising biochemical pathways for which researchers might be able to devise analgesic drugs.
I got injured last fall. The pain came on suddenly, more than 12 hours after my last run. All of a sudden, there it was, on the outside bony part of my foot. I took time off running, went to my primary doctor, took more time off running, went back to the doctor and then to an orthopedist, got a brace and finally resumed running.
All was well and good until I tweaked my foot again a couple of months later. I worried about the harsh pain returning and went back to the orthopedist, who gave me the option of going to physical therapy. He made sure I knew he didn’t think I absolutely needed it—I wasn’t in a ton of pain, after all—nowhere near the level when I originally injured my foot. I ended up signing up and going to two weeks of physical therapy sessions. It was one of the best decisions I could have made.
Add the Canadian Medical Association to the list of organizations shifting guidelines away from opioids in the treatment of chronic noncancer pain. In a set of updated recommendations that authors describe as consistent with US Centers for Disease Control and Prevention (CDC) guidelines, Canadian physicians are being urged to pursue nonopioid and nondrug treatments as a firstline approach.
The guidelines, published in the May 8 edition of CMAJ, are an update to opioid prescription guidelines released in 2010, in which “almost all supported the prescribing of opioids,” according to the new guidelines’ authors. The new recommendations take a markedly different position, advocating not just for nondrug approaches but also for lower dosages when opioids must be used, as well as for tapering programs for patients receiving high-dosage therapy of 90 milligrams or more daily.
The American Academy of Orthopaedic Surgeons (AAOS) is joining the fight against opioid abuse with a new public service campaign promoting conservative approaches—including exercise and physical therapy—as safe alternatives to painkillers.
The AAOS print campaign uses the message “Painkillers are easy to get into, hard to escape,” accompanied by an image of a person seemingly trapped inside a prescription container. According to AAOS, the ad has been distributed across the country.
In addition to the print efforts, AAOS also created 30- and 60-second radio ads, produced in partnership with the Orthopaedic Trauma Association, that dramatize a conversation between a physician and patient requesting more painkillers to help with recovery after knee surgery.
Andre Machado, MD, chairman of the Neurological Institute at Cleveland Clinic, thinks opioids are remarkable.
“But ‘remarkable’ can have 2 meanings,” he says. “It can be a positive remarkable, or a negative remarkable. And the long-term use of opioids, when we use it chronically, is often remarkable in the wrong direction.”
Now available from APTA’s Move Forward Radio: a conversation with Machado, who is leading an innovative pain treatment research project that puts a combination of physical therapy and behavioral therapy at the front lines of pain treatment, and takes a cautious approach to the use of opioids. Machado shared his thoughts on opioids and the need for a cultural shift on attitudes about pain in a recent TIME magazine opinion piece. His Move Forward Radio interview delves even deeper into his beliefs on what constitutes truly effective pain treatment.
A recent opinion piece in TIME magazine says that when it comes to pain treatment, unless a “fundamental mindset” is changed—a change that includes being “insistent” on the use of physical therapy in pain management—no real progress will be made in the fight to end the opioid abuse epidemic in the United States.
In “We’re All Responsible For Our Opioid Reliance—Even Patients,” Andre Machado, chairman of the Neurological Institute at the Cleveland Clinic, describes how opioids are little more than a “quick fix” for pain that miss what should be the true goal of pain treatment, which he describes as “recovery of function, not complete resolution of pain.”
“This crisis is a failure of our health care ecosystem and our quick-fix culture,” Machado writes. “We can all share the blame: physicians who feel anxious to meet patients’ expectations, pharma companies that oversell opioid benefits (and downplay the risks), insurers that fail to flag patients receiving high volumes of opioid prescriptions (and not properly reimbursing therapy) and patients who demand passive treatment.”
As if the national conversation over how pain is treated isn’t already complex enough, The New York Times (NYT) points out another important facet of the problem: regardless of where approaches may be heading in the future, pain treatment as it stands now is far from equal among racial minorities and whites.
“Finding Good Pain Treatment Is Hard. If You’re Not White, It’s Even Harder” combines interviews with research findings to highlight what NYT describes as a “persistent” problem: “Minorities tend to receive less treatment for pain than whites, and suffer more disability as well.” Among the findings reported in the story:
Blacks have been affected by the prescription opioid epidemic at “much lower rates” than whites.
A small insurer has taken a big first step in changing a dynamic that can lead to opioid abuse and addiction: Corvallis, Oregon-based Samaritan Health has announced that it has removed its prior authorization requirements and session limits for patients seeking physical therapy to treat pain.
According to the Lund Report, Samaritan will lift the requirement for members of its Choice plan as well as for beneficiaries in its Intercommunity Health Network, Samaritan’s Medicaid coordinated care organization. The change is intended to help decrease the use of opioids in the treatment of pain, particularly among patients with low back pain. The changes also apply to occupational therapy.
“Many studies now point toward movement therapy and exercise with body conditioning to help improve back pain,” explained Kevin Ewanchyna, MD, Samaritan Health Plan’s chief medical officer, to the Lund Report. “Physical therapists can provide the training and skill set to help the individual achieve their goals in exercise and movement therapy.”
Recently released US Centers for Disease Control and Prevention (CDC) prescription guidelines supporting nondrug, nonopioid treatments for chronic pain are among the resources that could help physicians and drug companies be held “more accountable” in the battle against opioid abuse and heroin use, according to President Barack Obama.
Obama made the comments during a meeting of the National Rx Drug Abuse and Heroin Summit held in Atlanta on March 29. The event, moderated by physician and media figure Sanjay Gupta, featured a panel of former addicts, physicians, and public health experts, and was aimed in part at highlighting White House efforts to gain support for an additional $1.1 billion requested this year to fight the abuse epidemic.
The conversation at the summit touched on the need for more and better-funded addiction treatment resources, reduced restrictions on the use of buprenorphine to treat opioid addiction, and an overall shift toward the view of addiction as a treatment problem rather than a law enforcement issue. But the discussion also addressed the ways in which the medical community has approached the treatment of pain through the use of opioids, and how that approach needs to change.