As we move away from opiates, what now for pain?
Chronic pain management has become increasingly complicated in the last few years as doctors look for solutions that are less dependent on opiates. John Bete Jr., DO, one of the experts at Cape Cod Healthcare’s Pain Management Center in Hyannis, recently talked with Cape Cod Health News about new advances in pain management and how doctors are using tools such as anti-seizure medications and tai-chi to help patients.
You talk about two kinds of pain: acute, which alerts us when there’s damage to our bodies, and chronic, which is managed, rather than cured. What do we need to understand about chronic pain?
Acute pain is what most people experience periodically through life. It's usually time-limited, so people get better. Most of what pain centers and pain physicians like myself treat is chronic pain. What's happened is this messaging system that tells when there's damage to your body is broken. Sometimes there's no damage that we can find in the body, but if you look really close at the spinal cord where the peripheral nerves meet the central nervous system, that's where the damage is taking place. That's what we call chronic pain. Chronic pain is a disease state unto itself.
You say chronic pain is “managed” rather than cured. What’s important for chronic pain patients to know?
When people have chronic pain, it's hard for others to understand what they're going through because most people don't have that. They get hurt, they get better, and they go on, whereas chronic-pain patients are living with some level of pain, and the nervous system has been altered.
We know that people are healthiest when they're active and they're moving around, and people who are [in pain] tend not to do that. One of the reasons you might give someone pain medicine is to keep them active and keep them functional.
What makes opiates so good at treating pain?
There's something called a runner's high. People will run for long periods of time. It's more and more fatiguing and painful and uncomfortable. They get to a certain point and suddenly they feel great. Their bodies are producing endorphins, which are your body's natural opiates. That reward center is to reward you for good behavior.
Opiates activate the brain’s reward system and produce analgesia (pain relief) and euphoria (elevated mood). The good part of that is we have this medicine that can give some relief for people who are suffering from the pain of a trauma or surgery. The danger is that in some people this system is hijacked by the opioids and the result is substance use disorder.
We know there are risks to opiates, such as dependence and addiction – or substance use disorder as it’s now called. Are there are other issues as well?
The most common problem is constipation, which can lead to a perforated bowel, if it is not addressed. The most dangerous problem is respiratory depression; the opioids decrease the reflex to breathe. When people die of an overdose, it’s usually because the opioids cause them to stop breathing.
Another issue with continued use of opioids at high doses is called “opioid-induced hyperalgesia.” Basically, the opioids, instead of lowering your pain, are actually elevating your pain.
You use a variety of medicines, including Tylenol: non-steroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen; antidepressants; muscle relaxants; anti-seizure and anti-spasticity medications; steroids; and opiates. How are pain management doctors approaching medication these days?
If you're going to focus on medicines, usually they talk about a polymodal approach: using low doses of everything, rather than large doses of any one medicine. A lot of medicines are available now that weren’t available 10 years ago. The opioid crisis has really driven research to find a lot of newer, different medications. Some of them are actually just rethinking older medications, but some of them are new molecules.
You also suggest other kinds of treatments, including podiatry, radiofrequency ablation, yoga and complementary medicine such as acupuncture. What else?
If someone's really struggling with this idea of (living with) chronic pain and I've done everything I can in terms of lowering their pain with medicines and injections, I want them to see a psychologist or a neuropsychologist who can help them with pain-coping techniques. I think it's under-utilized.
People oftentimes don't want that. They think you're telling them they're crazy or that it's all in their head. The reality is, pain is a perception, and the perception does occur in their head. Chronic pain is a very real thing and addressing the suffering it brings can improve quality of life and help the patient function better.
What can a patient expect when they come to the pain management clinic?
I'm trying to look at the things that I think are causing pain in that individual, so we do a detailed physical exam and a detailed history-taking. What happened to get them here? Other times, there are other multiple disease states or co-morbidities. They've got arthritis, and they've seen nine surgeons for different reasons. Some people have genetic disorders that are pretty painful conditions.
Then I talk with them and say, "What's the most important issue here? Is it the pain in your back? Is it your ability to do your laundry?" Often times I'm surprised by the answers (such as) "Well, I've been living with the back pain for a while, but I can't get up and down the stairs. I can't go upstairs to take care of my house."
It sounds like it’s important to manage our expectations for chronic pain?
Part of the treatment of pain is helping patients understand that they're in a chronic pain state, and this is probably not going to go away, and they shouldn't expect it to. If it's chronic pain that you're dealing with, the expectation has to be that this is just to control the pain enough so that you can function, and kind of learn to live with it. That’s the hard pill to swallow, no pun intended, when you've got chronic pain.