Strategy to Battle Opioid Epidemic Encourages Multilevel Approach

Washington University pain expert among researchers to author new recommendations

A new report from the National Academies of Sciences, Engineering and Medicine offers recommendations for how to address the nation’s ongoing opioid epidemic. Among the report’s authors was Jose A. Moron-Concepcion, an associate professor of anesthesiology at Washington University School of Medicine in St. Louis. (Photo: Robert Boston/School of Medicine)

Years of coordinated efforts will be required to contain and reverse the harmful societal effects of the country’s ongoing prescription and illicit opioid epidemic, according to a new report from the National Academies of Sciences, Engineering and Medicine (NASEM). The report, requested by the U.S. Food and Drug Administration (FDA) and published July 13, said it is possible to stem the still-escalating epidemic without eliminating access to opioids for patients who suffer from pain and whose providers prescribe the drugs responsibly.

The 18-person committee that authored the report recommended actions the FDA, other federal agencies, state and local governments, and health-related organizations should take — including promoting more judicious prescribing of opioids, expanding access to treatment for opioid-use disorder, preventing more overdose deaths, weighing societal impacts in opioid-related regulatory decisions, and investing in research to better understand the nature of pain and develop nonaddictive alternatives.

The committee was composed of experts involved in different aspects of pain management and opioid-use disorders. Among them was Jose A. Moron-Concepcion, associate professor of anesthesiology at Washington University School of Medicine in St. Louis. He studies the emotional component of pain and opioid receptors that modulate the sensory component of pain and the negative emotions associated with it. He discussed some of the key points addressed in the new report:

What is the status of the ongoing epidemic?

We were asked to characterize the epidemic and recommend actions the FDA and other organizations should take to respond. Overall, we found that the opioid epidemic is getting worse. Each day, 90 individuals in the United States die from an overdose that involves an opioid. Trends indicate that premature deaths associated with the use of opioids are likely to climb and that opioid overdose and other opioid-related harms will dramatically reduce the quality of life for many people in years to come.

What, in general terms, is recommended in the new report?

These are the key elements highlighted in the report:

• Changing the culture of prescribing, partially through enhancing education for physicians and the general public.
• Investing in treatment for the millions of individuals with opioid-use disorder and removing impediments to those treatments. Also, improving health-care provider education for opioid-use disorder.
• Preventing overdose deaths, including access to naloxone (also known by its brand name Narcan) and safer injection equipment.
• Weighing societal impacts, not just an individual’s, regarding opioids, such as incorporating public health considerations into the FDA’s current framework for making regulatory decisions regarding opioids.

•Investing in basic research, particularly to better understand the nature of pain and the neurobiology of the intersection between pain and opioid-use disorders. In addition, increasing the investment in developing nonaddictive alternatives to opioids for pain management.

Opioids are still known to be effective drugs for pain. How does the report balance the needs of patients who need pain treatment with reducing the availability of opioids?

When examining what actions to take, we also wanted to get the balance right and ensure that whatever measures we recommend to the FDA would still leave room for responsible prescribing and reasonable access for patients and physicians. As mentioned above, this also includes changing the culture of prescribing, which will necessitate improvements in education for the medical community, including establishing pain-education materials and curriculum for health-care providers. For the general public, we recommend evaluating the impact of patient and public education about opioids in an attempt to promote safe and effective pain management. The epidemic took nearly two decades to develop, and it will take many years to control, contain and reverse. Therefore, years of a sustained and coordinate effort will be required.

You and your colleague Adrianne Wilson-Poe, instructor in anesthesiology, recently published a review article about this problem, an update on where things stand regarding the chronic pain and opioid epidemics. Does this new report help to address some of the issues raised in your article?

Yes. As we also reported in our review article, we found that despite a decrease in the number of opioids being prescribed, many people who otherwise would have been using prescription opioids have transitioned to heroin, with a threefold increase in heroin-involved deaths from 2010 to 2014. Based on this, a change in prescribing and in patient behavior is crucial.

Importantly, our review also highlighted the need for a major investment in basic research to further elucidate the neurobiology of pain and opioid-use disorders. As mentioned above, the new report recommends a significant increase in funding to improve understanding of the neurobiology of pain, to support the discovery of innovative treatments and to improve understanding of the intersection between pain and opioid-use disorders.

Robert Boston Photographer
Jose Moron-Concepcion, Anesthesiology Pain Center

Jose A. Moron-Concepcion, associate professor of anesthesiology at Washington University School of Medicine in St. Louis, was on a committee that authored new recommendations on how to address the opioid epidemic. (Photo: Robert Boston/School of Medicine)

For more information on the report and a full list of committee members: http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=24781&_ga=2.109804423.365773662.1499961501-1180903414.1499439452

A Stimulating Approach to Relieve Back Pain without Opioids

As many as one in three Americans suffer from low back pain. Its economic impact is greater than that of heart disease and cancer combined.

Doctors who treat patients suffering from back pain are exploring new approaches that help some patients avoid opioid drugs. The highly addictive prescription painkillers are fueling an epidemic of abuse and overdose deaths.

One opioid-free option available at the Washington University Pain Center  involves stimulating the spinal cord with very short pulses of electricity. Patients can’t feel the electrical stimulation, yet it often effectively can mask the perception of pain.

Spinal cord simulation to relieve pain is not new. It was first introduced many years ago, but older stimulators produce a tingling sensation designed to replace pain with less unpleasant tingling. The newer, high-frequency spinal cord stimulators deliver more energy but without the tingling sensations.

“Patients with back pain have many treatment options, but many don’t get relief after surgery or injections,” said Michael Bottros, MD, Washington University pain management specialist. “Opioids can help some patients temporarily, and physical therapy also helps, but the new-generation stimulators fill an important niche, helping people return to normal activity without pain or the side effects that can result from opioids.”

ONE PATIENT’S STORY

Deanna Conley, of St. Louis County, had endured back pain for nearly 40 years.

Despite multiple surgeries, she needed a wheelchair to walk any significant distance. “I couldn’t cook a whole meal or even stand at the sink to wash dishes.  I had spinal injections and even saw a pain psychologist.”

In addition, she began to worry about the number of pain pills she took each day. “I was supposed to take one hydrocodone pill at night before bed,” Conley said. “But it got to where I was taking two pills a day and then three, and I worried I might end up being a drug addict at age 77.”

Dr. Bottros determined Conley was a good candidate for a high-frequency stimulator. Studies have shown the devices may be more effective in patients who have had previous back surgery but still have back pain. Research also indicates that although traditional stimulators work well when pain in the back is radiating into arms or legs, the high-frequency stimulators may be more effective when pain is located in the back itself.

“Traditional spinal cord stimulators provide a pleasant sensation in place of pain from sciatica problems or pain down the arm caused by cervical spine problems,” Dr. Bottros explained. “But for people like Ms. Conley, who had already had back-fusion surgery and still had pain, those older devices often aren’t as effective.”

Dr. Bottros inserted electrodes into the area of Ms. Conley’s back where her pain was most acute. The stimulator initially remained outside her back, but after verifying that the approach was having an effect, he used a minimally invasive technique to implant the entire device into the lower part of her back.

Ms. Conley reported a 70 to 80 percent reduction in back pain almost immediately. She is able to walk without assistance for considerably longer distances than she could before the stimulator was implanted, and she even registered for an exercise class.

She’s receiving physical therapy and getting stronger now that she is able to use muscles she couldn’t use previously because of her back pain.

“I feel like I’ve got a whole new lease on life. I’m going to dance at my granddaughter’s wedding!” Ms. Conley exclaimed.

IT’S A TEAM APPROACH

“It’s important that we use a team approach involving doctors, physical therapists and psychologists who help people focus their thoughts on things other than their pain,”  Dr. Bottros said. “Even when a device like this reduces pain, there still is muscle weakness to overcome, so patients need physical therapy to get stronger, to make sure they’re walking correctly and to focus on core stabilization to keep the pain in check.”

“Not long ago, we thought of pain as a symptom of some other underlying disease process,” Dr. Bottros said. “Now we’re learning that pain also may be a disease itself. And in this time of opioid abuse, we must be vigilant in insisting that pain-killing drugs aren’t overused.

Some patients benefit from opioids, but other interventions, combined with a multidisciplinary approach to care, may provide pain management without the adverse side effects and risks associated with opioids.”

For more information about spinal cord stimulation, or to make an appointment with Dr. Bottros, or one of our Washington University pain management specialists, please call:

Pain Management Center
Center for Advanced Medicine
4921 Parkview Place, Suite 14C
St. Louis, MO 63110
(314) 362-8820

Barnes-Jewish West County Hospital
969 N. Mason, Suite 240
St. Louis, MO 63141
(314) 996-8631

Missouri Baptist Medical Center
Pain Management Center
3015 N. Ballas Road
St. Louis, MO 63131
(314) 996-7200