Introduction
It is no secret that healthcare workers face many challenges in their career. Many healthcare professionals hold the fate of life altering decisions for their patients in their hands. In the area of chronic noncancer pain, these decisions can prove to be even more challenging to face. Through the use of decades of research, it has become possible for healthcare workers to begin to devise plans for chronic pain patients that both treat pain and guard against opioid addiction. Numerous strategies have been suggested and with the right combination and knowledge can potentially be quite effective.
In the past, opioids were frequently prescribed for the treatment of chronic noncancer pain (Grecu et al.). However, things like the introduction of OxyContin and the general over prescription of opioids throughout the 1990s lead to what we now refer to as the “opioid crisis” (Grecu et al.). In recent decades, the healthcare industry tightened up on the prescription of opioids for pain only to have new problems arise along with the new opioid regulations. As a result of the new restrictions on prescription opioids, it became more difficult than ever for patients to get and keep their prescriptions. Following this, the use and abuse for prescription street drugs such as heroin reached levels that have not been seen since the 1970s (Grecu et al.). Through trial and error of going between easy access to prescription opioids to making it nearly impossible to receive a prescription for opioids, the healthcare industry has begun to strive for a middle ground that both controls addictive behaviors and still provides relief for those who need it.
What Problems Do Healthcare Workers Face in Treating Chronic Pain?
The primary challenge healthcare workers face when trying to address chronic pain is finding a way to provide much needed relief without condoning or creating addictive behaviors in their patients. Many healthcare professionals struggle to find this balance between helping and hurting when trying to come up with treatment strategies for their patients and are, therefore, reluctant to prescribe opioids at all (Krashin et al.). If prescription pain treatments were developed to help those in pain, shouldn’t chronic pain patients be able to access them? Although healthcare providers do their best to help, there are a number of issues that make it complicated to treat chronic pain and many solutions have been attempted with limited results. There are a few key issues which must be understood and addressed before treatment options can be observed. The complicated nature of pain treatment and challenges that are faced in creating treatment strategies should not stop those who are in pain from receiving help. There should be a uniform treatment strategy for addressing chronic pain.
One of the first challenges that healthcare workers face when prescribing prescription opioids is that it can be very challenging to manage addictive behaviors in patients and once patients develop a dependency or addiction to their pain medications, it can be incredibly difficult to break said dependency (Holmes). Often times patients who have developed an addiction or dependency to their pain medications do not experience any actual desire to stop taking their medications, but only aim to reduce their dosage (Holmes). While this is helpful to prevent overdose since there is a direct correlation between higher opioid dosage and higher overdose rates, reducing the dosage does not by itself take away the dependency on the drug(s). The actual health benefits from a reduced dosage are negligible if long term substance abuse continues (Holmes).
There are ethical challenges that arise regarding weaning patients off medications by their healthcare providers because of patients' right to choose and autonomy (Sud et al.), among other things. While healthcare professionals are no doubt aware of the dangers of addiction when prescribing opioids to their patients, many of them are under extreme pressure from their patients and their patients' families to make the pain stop and improve the quality of life for their patients (Krashin et al.). The social and emotional aspect of treatment between a doctor and patient can make doctors feel compelled to prescribe pain medications to provide immediate relief for their patients' discomfort even if that may not be the best option necessarily. This is discussed by Krashin in the paper saying:
Primary care providers have frequently been sought out to provide relief for distressed patients. As some primary care providers and clinics have declared that they will no longer prescribe opioids at all, or will only prescribe them for cancer pain, the pressure has increased on other providers. (Krashin et al.)
Krashin illustrates the ethical complications of the patient/physician relationship with this point, primarily focusing on the pressure placed on providers by distressed patients.
Prescription Drug Monitoring Programs for Opioid Regulation
When doctors do prescribe prescription opioids to patients who are at risk for developing an addiction, there is a high-risk patient treatment strategy which should be followed to prevent an addiction from developing (Krashin et al.). Furthermore, risks such as these are why medical professionals are continuously attempting new methods to regulate their patient's use of prescription opioids (Appold). One of the first methods that was implemented to try and regulate the abuse of opioids in patients was the implementation of prescription drug monitoring programs (Grecu et al.).
When prescription drug monitoring programs were first introduced, many of them were not mandatory for clinicians to use when prescribing opioids. The era of non-mandatory prescription drug monitoring programs coincided with the times before computers were widely used. Using the first prescription drug monitoring programs was difficult and time consuming to do with the computers of the time, so many clinicians opted out of using them (Grecu et al.). Along with many medical professionals neglecting to use the prescription drug monitoring programs at all, the few who did were often met with incomplete and inaccurate data because other healthcare providers had not uploaded their information to the database (Grecu et al.). All of this rendered the intended effects of the non-mandatory prescription drug monitoring programs null. Studies conducted to review the use of non-mandatory prescription drug monitoring programs concluded that the effectiveness was minimal because of the lack of proper usage (Grecu et al.). Ultimately, the prescription drug monitoring program was a good idea, but it had to be tweaked in order to be effective. This led to the implementation of the mandatory prescription drug monitoring programs. These new changes made it mandatory for all clinicians to upload the information about their patients to the database for shared use across the medical field by other healthcare professionals (Grecu et al.).
While prescription drug monitoring programs proved effective to stop the abuse of prescription opioids, two other problems arose with its implementation. One, the mandatory prescription drug monitoring programs and other policies that had been implemented along the way now made it too difficult for patients to gain access to prescription pain medications when they needed them. Two, the patients who were already abusing prescription opioids found new methods to self-medicate such as the abuse of heroin and methadone (Krashin et al.). This hyper-restriction of prescription opioids brought with it a need to learn new methods to council chronic pain patients in coping with their symptoms.
With these restrictions for prescription opioids in place, alternative methods for managing chronic pain had to be researched. While these alternative methods were found to be effective on their own, they have also been implemented to use in combination with prescription opioids. Providing education and self management techniques were found to be helpful in allowing patients to learn to manage their own pain without opioids (Joypaul et al.). Primarily the methods that have been investigated are cognitive behavioral therapy, alternative therapies, and holistic therapies. Over time these therapies coupled with prescription opioid use have made it possible to provide a three pronged approach to chronic pain management.
Evolution of Alternative Pain Management Techniques for Chronic Pain
In recent years there have been great strides made in the self-management of chronic pain as well as strides made in the areas of holistic and alternative therapies for treating chronic pain. Further studies in the areas of psychology and cognitive behavioral therapy have led to advancements in chronic pain management techniques as well as self-management and self-regulation of prescription opioids. Krashin discusses the need to implement a multi-disciplinary approach to opioid management saying, “Behavioral specialists can also be extremely helpful to primary care physicians in assessing and managing the risk of opioid misuse and abuse” (Krashin et al.). One of the things Krashin discussed in his paper is the impact of behavioral specialists on substance misuse and abuse in relation to prescription opioids for pain management. Cognitive behavioral therapy, according to Krashin, has been proven to provide chronic pain patients with tools and coping skills to manage their pain and their substance use. Also, therapists can provide valuable insights into which patients may be high risk and need special attention during treatment.
Recent breakthroughs in the area of opioids for chronic pain management along with the therapeutic approaches have given way to a three-pronged approach to managing the use of prescription opioids among chronic pain patients (Appold). This provides a relaxation of the hyper-restriction on opioids that were put in place previously. This approach combines opioids with cognitive behavioral therapy and holistic and alternative therapies. Studies have found that by combining all three of these methods, pain can be effectively managed and the instances of substance abuse among patients are significantly reduced (Mann et al.).
Opioids provide something of a band-aid solution to pain which allows for short term relief among patients to allow for other management techniques to take place. Cognitive behavioral therapy uses behavior based strategies to teach patients how to effectively cope with the psychological aspects of their symptoms. This can help prevent substance abuse as well as teaching stress-reduction techniques to help alleviate pain that is caused by environmental stressors (Davis et al..). Holistic therapy is a mind and body centered approach which aims to reduce stress and pain through techniques such as yoga, acupuncture, massage and other physical methods. Many of the holistic approaches aim to reduce systemic inflammation which provides some relief for chronic pain. Appold discusses the importance of alternative therapy such as acupuncture and chiropractics saying, “Some patients get better with the trial of conservative care and never need an opioid prescription . . . Others report that after starting chiropractic care, they no longer feel the need to take the opioids they were previously prescribed.” (Appold)
Appold's discussion of the benefits of alternative therapies provides evidence that the use of alternative therapies are effective for helping to manage chronic pain.
Alternative therapies focus on things such as herbal remedies as well as nutritional supplements for pain management and overall wellbeing. Combining these three approaches is intended to reduce stressors that encourage substance abuse, teach stress management techniques to cope the psycho-emotional aspects of chronic non-cancer pain, and reduce the need for prescription opioids by alleviating pain and discomfort through natural methods. By teaching natural methods such as these, preventative measures are being implemented in treatment to help prevent the development of addiction.
In addition to this multi-dimensional approach, there have also been breakthroughs in other therapeutic methods. Things like pain pumps, ketamine and lidocaine infusions, TENs units, sensory deprivation, float therapy, and intravenous vitamin infusions have all been investigated to help chronic pain. Many chronic pain patients use a mix of all of these methods to manage their pain. (Appold)
Pain pumps have been suggested as an alternative to prescription opioids for chronic pain in a specific location such as the spinal cord. Pain pumps may be installed at the site of pain to inject pain medications directly into the pain site rather than being distributed throughout the bloodstream as is typically seen with the use of prescription opioids. (Appold) Ketamine and lidocaine infusions are chronic pain therapies in which patients go to an infusion center as often as every two weeks or as far apart as twice per year as determined by their physicians to receive intravenous infusions of pain medications. The dosage and timespan between infusions is determined by physicians and allows for regulated access to long-lasting pain medications which significantly decreases the ability to abuse these pain medications. TENs units are small machines which distribute electrical signals into pain sites through the use of small sticky patches which are placed on the skin. TENs units provide an effective pain management route because they are small items which are cheap enough for most patients to afford, and the treatments only take twenty to sixty minutes to administer. Sensory deprivation therapy works by blocking out the sensations of sight, sound, touch, and hearing as much as possible to allow for full body relaxation and a reduction in the output of stress hormones from the brain which cause widespread inflammation. Float therapy is a method of sensory deprivation therapy in which the patient goes into a tank that blocks light and sound, is temperature regulated to the exact temperature of skin, and filled with Epsom salt water. The patient floats in the water of the tank and without sight, sound, smell, or touch, and experiences almost complete sensory deprivation. The magnesium from the Epsom salt also absorbs into the skin and muscles to provide pain relief. The anti-gravity effects of floatation therapy have been proven to aid in elongation of the spine and joints which helps to relieve spine and joint pain. Lastly, intravenous vitamin infusions have been implemented in the treatment of chronic pain. Much like lidocaine and ketamine infusions, vitamin infusions are provided by a healthcare provider at a pre-determined interval for treatment. The direct infusion of vitamins into the bloodstream allows for greater access to the vitamins for healing nerve damage, acute injuries, and reducing systemic inflammation.
Conclusion
While all this information is helpful and hopefully provides an avenue for chronic pain patients to pursue relief from their symptoms, there is always the objection that patients do not always want to do what is in their own best interest. Unfortunately, abusing medications is easier than working in tandem with doctors, therapists, acupuncturists, and other professionals to manage chronic pain. There is always the argument that patients would rather take opioids to mask the pain rather than putting forth the effort to try and facilitate true pain reduction through lifestyle changes. While these worries are true and justified, there should still be avenues of treatment for those who are willing to make the effort to change. Ultimately there is nothing that can be done for patients who are determined to abuse the substances that they are provided for pain relief, but having pain management strategies that are available and accessible does help to reduce the number of patients that will abuse their prescriptions. The patients who would rather abuse their medications than implement treatment strategies properly will gain access to medications one way or another. Having these treatment strategies in place reduces the number of patients who feel the need to abuse their prescriptions by providing other avenues of pain relief and, furthermore, helps to reduce the overall number of patients that will go on to abuse substances after gaining access to them.
With all the available treatment options for the management of chronic pain, the risk of opioid addiction is significantly reduced by providing patients with other coping mechanisms. Many chronic pain patients are unable to work due to their conditions. They want to desperately reintegrate into society and be able to participate socially, emotionally, and financially in their families and communities. Prescription opioids were designed to provide this relief and give patients the ability to cope with their conditions and continue to participate in society, despite their limitations. Restricting the use of prescription opioids defeats the very purpose they were intended. The breakthroughs in pain management techniques over recent decades have provided hope and help in managing chronic pain. With the multi-dimensional approaches in place, it is now much safer to prescribe opioids than it was in the past. With increases in safety measures and pain management techniques it is now safer than ever to prescribe opioids for pain management and all chronic pain patients should have the option to use them as a part of their therapy.
Works cited
Appold, Karen. “Rx for Preventing Opioid Addiction.” Managed Healthcare Executive, vol. 28, no. 1, 2018, pp. 19–20.
Davis, Mary C, et al.. “Mindfulness and Cognitive-Behavioral Interventions for Chronic Pain: Differential Effects on Daily Pain Reactivity and Stress Reactivity.” J Consult Clin Psychol, vol. 83, no. 1, 2015, pp. 24–35., doi:10.1037/a0038200.
Grecu, Anca M, et al.. “Mandatory Access Prescription Drug Monitoring Programs and Prescription Drug Abuse.” J Policy Anal Manage, vol. 38, no. 1, 2019, pp. 181–209., doi:10.1002/pam.22098.
Holmes, David. “Prescription Drug Addiction: the Treatment Challenge.” Lancet, vol. 379, no. 9810, 2012, pp. 17–18., doi:10.1016/S0140-6736(12)60007-5.
Joypaul, Shirdhya, et al.. “Multi-Disciplinary Interventions for Chronic Pain Involving Education: A Systematic Review.” PloS One, vol. 14, no. 10, 2019, pp. e0223306–e0223306., doi:10.1371/journal.pone.0223306.
Krashin, Daniel, et al.. “Challenges to Treatment of Chronic Pain and Addiction During the ‘Opioid Crisis.’” Curr Pain Headache Rep, vol. 20, no. 12, 2016, pp. 1–3., doi:10.1007/s11916-016-0596-2.
Mann, Elizabeth G, et al.. “Self-Management Interventions for Chronic Pain.” Pain Management (London), vol. 3, no. 3, 2013, pp. 211–222., doi:10.2217/pmt.13.9.
Sud, Abhimanyu, et al.. “Chronic Pain and Opioid Prescribing: Three Ways for Navigating Complexity at the Clinical‒Population Health Interface.” Am J Public Health, vol. 112, no. S1, 2022, p. S56.
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