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Pain Management Treatment—Then and Now

Pain management treatment has come a long way over the last couple of decades. When I first started practicing medicine in the late 1990s, if a patient had a back injury, you’d write them a prescription for 30-40 tabs of Vicodin or Percocet and have them take it every six hours. It was all about relieving the pain. The standard of care seemed to be about pain relief not returning to function quickly. Medications could go on for months. That’s when addiction and pain management started sometimes to become intertwined.

Chronic Pain Management Today

Comparing how you treat a pain management patient diagnosed in 2000 versus 2018 is like comparing apples to oranges – it’s two different treatment regimes. Today, you would never prescribe narcotics in the amount we were in the 90s. Most of today’s pain management patients are barely on narcotics, if at all. Pain management doctors typically use a combination of traditional and alternative approaches that may include:

Nonsteroidal Anti-Inflammatory Drugs and Acetaminophen

A high dose of acetaminophen or ibuprofen and perhaps a small amount of oxycodone may be prescribed for chronic pain management. Nonopioids like Tylenol and Motrin have been shown to work just as well as opioids in managing some types of pain.

Aggressive Physical Therapy and Occupational Therapy

There are now outcome data that shows we should proactively treat acute pain with things like PT and OT from the beginning. You don’t sit on it and wait for the pain to subside with medication before starting these activities.

Exercise and Stretching

It seems counterintuitive to exercise when one’s in physical pain, but gentle activity tailored to the individual is much better than staying in bed. Physical activity can keep muscles and joints flexible, help restore functioning and strength, and release endorphins that fight pain naturally as well as improve mood.

Holistic Approaches

Alternative approaches like acupuncture, hypnotherapy, and biofeedback can be effective complementary approaches to traditional chronic pain management approaches. Even though there’s still work to do, we’ve come a long way. Dispensed opioid prescriptions saw their biggest drop in 25 years in 2017 according to data by IQVIA’s Institute for Human Data Science. Additionally, opioid prescriptions for doses that bring the most risk of dependency and overdose decreased by 16.1% last year. There are a few reasons for this.

Why the Decline in Opioid Prescriptions?

The epidemic number of opioid overdoses and deaths that came to light around 2010 fueled most of the addiction and pain management initiatives that have shown a downward trend in narcotic painkiller prescriptions.

Re-education and New Research

As with any medical condition, how you treat it changes as research evolves. The way we treat addiction today is not how we did 30 years ago. Same with diabetes and other chronic illnesses. Chronic pain is no different. In the 1990s and early 2000s, there was a huge push in the medical community to eliminate pain in patients through whatever means necessary. Usually, this included opioids like OxyContin and Vicodin. Many of those patients developed pain pill addiction. Now, research shows treating conditions like knee, neck, and chronic back pain with nonopioids is just as effective as opioids. We’ve also gotten better at being more selective with epidurals and other types of former go-to narcotics for pain.

Crackdown by DEA

The Drug Enforcement Administration has been putting increasing amounts of pressure on heavy opioid prescribers since around 2007. Doctors always knew the DEA was watching. When the heroin epidemic started gaining press, it went up a few notches. Every month the DEA gets a registry of what’s been written. I know of five to ten doctors the DEA shut down for overwriting. They lost their licenses. And it’s been a trend. In fact, they just revoked the licenses of 147 people involved in controlled substances and arrested 28 prescribers as part of a review of drug transactions. 

Pressure from Professional Associations and the CDC

Organizations, like the American Dental Association (ADA) and the American Medical Association (AMA), have sent out guidelines for decreasing or eliminating the use of opioids for pain management. Some doctors get jumpy when organizations like these try to restrict them. While these are just suggestions, not laws, it’s possible it may have helped contribute to the decline. The Centers for Disease Control and Prevention (CDC) also issued guidelines that basically say a seven-day supply of opioids for the treatment of acute pain is rarely needed, and doctors should limit prescriptions to three days. Again, not law, but these guidelines do come with some weight and may help curb pain pill addiction.

Dosage Restrictions and Guidelines

As of April 2018, 28 states have legislation, requirements, or guidance on prescribing opioids for acute pain (there are typically exceptions for chronic pain). Some drug store chains like CVS as well as certain insurance plans have imposed similar limits. There’s currently a bill in Congress to restrict opioid prescriptions for acute pain to three days.

Public Awareness

You see a story in the news or on social media about the opioid crisis pretty much every day. Most people are aware of the link between prescription painkillers and heroin abuse and the dangers of opioid painkillers. A lot of people are going to be more cautious about using these types of drugs if their doctor or dentist prescribes them. Despite those measures, drug overdose deaths continue to rise in the U.S., and the CDC reports emergency rooms saw a large increase in opioid overdoses last year. Reducing opioid prescriptions is only one piece of the puzzle in getting a handle on the opioid crisis and changing these numbers.

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