Pain is a condition everyone experiences and must learn to manage. Treating this pain has quickly become one of the largest costs taxing the economy. In fact, at around $600 billion in health care fees and lost productivity, pain management exceeds the costs of heart disease and cancer combined. The opioid epidemic has affected people of all incomes, genders, and race. The most current numbers as of September 2018 show that 72,000 individuals died from fatal overdoses last year of which nearly 50,000 involved opioids. Here is an infographic of statistics from 2016:

Source: https://www.hhs.gov/opioids/sites/default/files/2018-09/opioids-infographic.pdf

Treating pain also has led to a major unintended consequence: a reliance on addictive pills that has created one of the largest heath crises of our time. The 2017 article, How good intentions contributed to bad outcomes: The Opioid Crisis details a few of the reasons this occurred.

1. A 1980s letter to the editor of the New England Journal of Medicine indicated that opioids were not as addictive as believed. This initiated the transition to using opioids to fight any pain, versus acute pain or terminal illnesses.
2. This new belief changed the perception for doctors and thus many doctors didn’t know the potential addictive quality opioids could have.
3. OxyContin was approved by the FDA in 1998 and false marketing led to a huge increase in opioid prescriptions.
4. Patients began to directly influence the amount of opioids they received as patient satisfaction surveys became a proxy of quality care.
5. Doctors and hospitals started earning bonuses or other rewards for higher patient satisfaction scores.

This confluence of events, beliefs, and factors created the perfect conditions for the current opioid crisis, and because the cause was multidimensional, the solution will necessarily be comprehensive.

The President’s Commission on Combating Drug Addiction and the Opioid Crisis recommends a collaboration between behavioral health professionals, medical professionals, the government, business leaders, academic institutions and others to fight this crisis.

As part of a comprehensive effort, this Fall the Nevada Division of Public and Behavioral Health and SAMHSA’s State Targeted Response to the Opioid Crisis are bringing two individuals from the medical field to share valuable new tools and innovative ideas on how to best find a solution to this epidemic. Alexis LaPietra, DO and Mark Rosenberg, DO will present on their Alternatives to Opioids (ALTO) Program in Nevada on November 13^th and 14^th. The seminar will present “evidence to support the use on non-opioid medication and modalities and the future of pain management and addiction medicine in the acute care setting.” Created at the Emergency Department at St. Joseph’s University Medical Center in 2016, ALTO brings a “multidisciplinary acute pain management program that not only helps patients with painful conditions without using opioids, but also helps those patients with drug dependency and addiction.” The presentation will explain the process that helped their emergency room reduce opioid prescriptions by over 20%: great results during the initial study.

In the study researchers explain the thought process behind the protocols of the ALTO Program. The goal of the ALTO program is to prescribe opioids only as a last resort. Instead doctors would spend more time initially communicating with patients and use other treatments such as nerve blocks, anti-inflammatory drugs, Tylenol and IV lidocaine to help alleviate pain. The five health conditions that the St. Joseph Emergency department focused on were:

• Headache
• Kidney stone
• Low back pain
• Musculoskeletal pain
• Fractures and dislocations.

The success of this program indicates that there is hope in combating the crisis from a medical perspective. It also brings up a question for professionals in the non-medical field: what other alternatives could be developed or are already known that behavioral health professionals can propose/practice to combat the crisis and the underlying factors that caused it?

Medicine often provides the fast relief patients desire; however, it is not the only way to alleviate pain. Research shows that alternatives exist. Here are five suggestions to try as an alternative to opioids.

1. Virtual Reality (VR) is quickly becoming recognized as a beneficial method of treatment. According to the Virtual Reality Society, VR is used to describe a three-dimensional, computer generated environment which can be explored and interacted with by a person. A study by Rutter et al. that tested participants tolerance to cold found that VR distraction led to significance in pain threshold and tolerance and decreases in pain intensity (2009). A different study, testing pain in hospitals found VR is not only safe but significantly reduces pain versus control conditions. A third study out of the University of Washington tested VR with burn patients. For this study Dr. Hoffman and his colleague David Patterson created an immersive VR game called SnowWorld to help distract people during challenging medical procedures. By playing a simple game, that involves throwing snowballs at penguins, burn patients showed 30-50% less pain according to brain scans in a fMRI (Hoffman, et. al, 2011).

2. Hypnosis, according to the American Psychological Association (APA), is a “set of techniques designed to enhance concentration, minimize one’s usual distractions, and heighten responsiveness to suggestions to alter one’s thoughts, feelings, behavior, or physiological state.” Researchers Guy Montgomery, Katherine Duhamel, and William Redd performed a meta-analysis on hypnosis on pain management (2000). They found that 75% of clinical and experimental participants with various types of pain gained substantial relief from hypnotic techniques. However, the authors found that most practitioners believe that the greatest results occur when hypnosis is used with other psychodynamic or cognitive-behavioral therapies. Another study found that although there is still much to learn about hypnosis, current knowledge shows that on average, hypnosis is effective for reducing chronic pain intensity. The study maintains that hypnosis has no negative side effects and after treatment individual gain positive effects such as improved sleep and a higher sense of well-being. While individuals have different levels of hypnosis susceptibility, and hypnosis may not work with everyone, it does offer, especially in combination with other treatments, another proven alternative to opioids for pain management (Jensen, M.P., and Patterson, D.R., 2014).

3. Acupuncture is an ancient form of medicine from Asia that is used to relieve pain and to improve sleep and a person’s overall sense of well-being. It works by inserting small needles into specific “acupoints” that promote energy flow and helps stimulate various systems to improve the body’s natural self-healing process. The traditional Chinese method, often considered alternative and holistic, approaches this phenomenon in more of the psychological sense by creating a balance in the yin and yang of the body. In the last few decades the “magic” of acupuncture has started becoming the science of the West. In the United States acupuncture is now considered conventional medicine as it uses current knowledge of anatomy, physiology, and pathology in its approach. Western acupuncture uses needles to stimulate the nervous system to treat musculoskeletal pain as well as ease lower back pain, nerve pain, headaches, nausea, fibromyalgia and other ailments. While there is some controversy to the degree of benefit caused by the actual needles used in acupuncture, a meta-analysis on acupuncture for the treatment of chronic pain shows that the overall experience is effective for treating chronic pain. Researchers found that participants on average had greater pain reduction using actual acupuncture versus control and “sham” acupuncture. This is best explained by the findings that about half of participants felt 50% improvement after acupuncture versus 42.5% and 30% for sham and control groups respectfully (Vickers, et. al, 2012). When starting any new program, it is important to consult a physician and work with certified individuals from the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) or similar standards for your specific state or country.

4. Mindfulness according to the Greater Good Science Center at Berkeley, is moment by moment awareness of thoughts, feelings, body sensations, and the surrounding environment through a gentle and nurturing lens. It involves paying attention to our thoughts and feelings without judgement. John Kabat-Zinn, of the University of Massachusetts, helped bring the benefits of mindfulness mainstream with the development of his Mindfulness Based Stress Reduction (MBSR) Program. A systematic review out of the “Obstetrics and Gynecology” Journal studying meditation and chronic pain shows that while not directly healing pain, mindfulness helps the body relieve stress, anxiety, exhaustion, depression, and irritability: all contributing factors of pain, and thus improving quality of life of many patients (Ball, EF et. al, 2017). An examination of multiple studies looking at Mindfulness-based interventions (MBIs)for chronic pain found that mindfulness alone helped the treatment of low back pain, headaches and musculoskeletal pain at a similar level to other standard treatments like cognitive behavioral therapy (CBT) (Majeed et. al, 2018). Mindfulness also helps with the accompanying factors of pain such as anxiety and depression. This video provides a brief introduction to the physical and psychological changes that mindfulness has on the body. Two simple examples of ways that a person can practice mindfulness are through breath meditation and a body scan. In breath meditation a person focuses on the breath and gently returns the focus to the breath when the mind wonders. During a body scan the individual focuses of how each part of the body is feeling during that specific moment. Both techniques are useful in helping the mind better process the actual pain and the brains reaction to the pain.

5. Exercise – A systematic review of studies examining the effects of exercise on chronic low back pain looked at fourteen studies of the effects of physical activity on lower back pain. Authors Gordon and Bloxham found that an exercise program combining strength training, flexibility, and aerobic fitness was beneficial in treating non-specific chronic low back pain. Exercise increases blood flow and nutrients to the back which improved the healing process that caused the back pain (2016). In addition, a review and evaluation of current literature  examining the benefits of exercise for several conditions causing chronic pain showed “incontrovertible evidence” that regular physical activity contributes to the primary and secondary prevention of cardiovascular disease, Type 2 Diabetes, and some cancers, and reduces the chance of breaking bones. The review also found that exercise also improves mental health and reduces the risk of premature death (Warburton, et. al, 2006).

Research continues to support the benefits of treatments other than opioids as the appropriate first choice for helping manage patients’ pain. The American College of Physicians published new guidelines (2017) highlighting various other options to assist with patients with acute and chronic lower back pain. They recommended various other options including massage, heat, cognitive behavior therapy, and muscle relaxants along with Advil/Tylenol. Harvard Health Publishing provides several more non-opioid options including cold laser therapy, biofeedback, and psychotherapy.

In short, current research supports the effectiveness of numerous alternative techniques for both acute and chronic pain management. Healthcare providers can be assured that the evidence confirms that choosing from a combination of one or more of the many available alternatives prior to resorting to opioid treatment is sound, evidence-based practice. Further information on opioids and other behavioral health topics can be found on the CASAT OnDemand. Feel free to share other alternatives that have worked in the past.

Here is the link to the ALTO training on November 13^th and 14^th.

References

Ball, E. F., Nur Shafina Muhammad Sharizan, Emira, Franklin, G., & Rogozińska, E. (2017). Does mindfulness meditation improve chronic pain? A systematic review. Current Opinion in Obstetrics & Gynecology, 29(6), 359.

Duncan, R. W., Smith, K. L., Maguire, M., & Stader, 3., Donald E. (2018). Alternatives to opioids for pain management in the emergency department decreases opioid usage and maintains patient satisfaction. The American Journal of Emergency Medicine, doi:10.1016/j.ajem.2018.04.043

Gordon, R., & Bloxham, S. (2016). A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare, 4(2), 22. http://doi.org/10.3390/healthcare4020022

Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Washington (DC): National Academies Press (US); 2011.

Jensen, M. P., & Patterson, D. R. (2014). Hypnotic approaches for chronic pain management: Clinical implications of recent research findings. The American Psychologist, 69(2), 167-177. doi:10.1037/a0035644

Madras, B. K. (2018). The president’s commission on combating drug addiction and the opioid crisis: Origins and recommendations. Clinical Pharmacology & Therapeutics, 103(6), 943-945. doi:10.1002/cpt.1050

Majeed, M. H., Ali, A. A., & Sudak, D. M. (2018). Mindfulness-based interventions for chronic pain: Evidence and applications. Asian Journal of Psychiatry, 32, 79-83. doi:10.1016/j.ajp.2017.11.025

Montgomery, Guy & Duhamel, Katherine & H. Redd, William. (2000). A meta-analysis of hypnotically induced analgesia: How effective is hypnosis?. The International journal of clinical and experimental hypnosis. 48. 138-53. 10.1080/00207140008410045.

Qaseem, A., Wilt, T. J., McLean, R. M., Forciea, M. A., Clinical Guidelines Committee of the American College of Physicians, & for the Clinical Guidelines Committee of the American College of Physicians. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the american college of physicians. Annals of Internal Medicine, 166(7), 514. doi:10.7326/M16-2367

Rummans, T. A., Burton, M. C., & Dawson, N. L. (2018). How good intentions contributed to bad outcomes: The opioid crisis. Mayo Clinic Proceedings, 93(3), 344-350. doi:10.1016/j.mayocp.2017.12.020

Rutter, C. E., Dahlquist, L. M., & Weiss, K. E. (2009). Sustained Efficacy of Virtual Reality Distraction. The Journal of Pain : Official Journal of the American Pain Society, 10(4), 391–397. http://doi.org/10.1016/j.jpain.2008.09.016

Tashjian VC, Mosadeghi S, Howard AR, Lopez M, Dupuy T, Reid M, Martinez B, Ahmed S, Dailey F, Robbins K, Rosen B, Fuller G, Danovitch I, IsHak W, Spiegel B, Virtual Reality for Management of Pain in Hospitalized Patients: Results of a Controlled Trial JMIR Ment Health 2017;4(1):e9 DOI: 10.2196/mental.7387 PMID: 28356241 PMCID: 5390112

Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., MacPherson, H., Foster, N. E., . . . Acupuncture Trialists’ Collaboration. (2012). Acupuncture for chronic pain: Individual patient data meta-analysis. Archives of Internal Medicine, 172(19), 1444-1453. doi:10.1001/archinternmed.2012.3654

Warburton, D. E. R., Nicol, C. W., & Bredin, S. S. D. (2006). Health benefits of physical activity: The evidence. CMAJ : Canadian Medical Association Journal = Journal De l’Association Medicale Canadienne, 174(6), 801-809. doi:10.1503/cmaj.051351

White, A., Editorial Board of Acupuncture in Medicine, & Adrian White and Editorial Board of Acupuncture in Medicine. (2009). Western medical acupuncture: A definition. Acupuncture in Medicine : Journal of the British Medical Acupuncture Society, 27(1), 33-35. doi:10.1136/aim.2008.000372