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Opioids to treat long-term, non-surgical spinal conditions can be detrimental What is the role of opioids in the nonoperative treatment of chronic spine problems?
There is a role for opioids in the treatment of non-surgical spinal conditions, according to Stuart B. Kahn, MD, of Mount Sinai Medical School, in New York. But it is when physicians use opioids as a cure-all for these conditions, he said, that causes the most problems.
“I think, though, that spine pain is not really an accurate diagnosis, and to use opiates safely, one must know exactly what condition they are treating. For example, you have to realize that spine pain is a symptom; it is a category of multiple diagnoses that needs to be diagnosed and treated properly,” Kahn told Spine Surgery Today. “The single most important thing for opioids in pain management is to make sure you are using it for the appropriate measures. Using opioids after other pharmacologic treatments and other modalities have failed for bone, joint, soft tissue and scar pain is appropriate. Using opioids for something like nerve pain, which does not always help, when there are better and safer agents, would be unwise. You want to safeguard your patients. You want to make sure you are protecting them against the side effects of the opioids if other pain modalities have failed,” Kahn said.
Rise of opioids
Opioid use began to increase dramatically in the United States in the 1990s. A frequently cited study published in 1986 by Portenoy and colleagues said pain was vastly undertreated in the United States and opioid use was a possible answer, Clinton James Devin, MD, of Vanderbilt Spine at NorthCrest Medical Center, in Springfield, Tenn., said.
The study — “Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases” — was the backing in the early 1990s for the nationwide increase in opioid prescriptions. The investigators in the study concluded opioid maintenance therapy could be a safe alternative to the options of surgery or no treatment for patients with no history of drug abuse and intractable non-malignant pain, according to Devin.
“The study said that pain was significantly undertreated and they [opioids] did not lead to any dependence or bad effects. CMS and other national payers and policymakers started to recognize this and said pain was undertreated. They wanted to track and measure hospitals adequately controlling pain,” Devin said. “In the 1980s, narcotics were not used for chronic syndromes. But then a shift occurred, and they started to be prescribed liberally. Then, in about 15 years, you saw a significant rise in opioid use.”
Opioid overdoses on the rise
According to the Centers for Disease Control and Prevention, about 3,000 deaths occurred in the United States in 1999 due to an unintended overdose of opioid analgesics. By 2007, that figure had increased to about 12,000 deaths, more deaths than for cocaine and heroin overdoses combined.
In a 2012 article in the Wall Street Journal that discussed the effect Portenoy’s study had on the increase of opioids in the United States, Portenoy was quoted as saying, “Clearly, if I had an inkling of what I know now then, I wouldn’t have spoken in the way that I spoke. It was clearly the wrong thing to do.”
Devin said what you see now when you look at the literature is that giving opioids for chronic conditions can be “horrible. It is not a good thing to do.”
Use in acute conditions, infection
Using opioids to treat acute spinal conditions in patients as a means to keep them out of the emergency room is appropriate, Jason Lipetz, MD, of Long Island Spine Rehabilitation Medicine, told Spine Surgery Today. They can be a useful tool to manage a patient’s pain in the short term until another treatment can be crafted for the patient that may have better long term results without the overall complications of an opioid.
Jason Lipetz
“Where we find the most appropriate use of opioids is when someone is in intense pain and we are trying to keep them out of the emergency room and manage their pain,” Lipetz said. “Opioids may buy us some time as we introduce anti-inflammatory measures to a patient, such as a spinal injection, or oral steroids,” he said.
Patients with acute spinal fractures or who may have pain due to a spinal infection are also candidates for opioids, Lipetz said, but the continued use of opioids in their management can pose a number of potential complications.
“When you are dealing with elderly patients who may have osteoporotic fractures and they are using opioids, it can increase their risk of falling. It can reduce their cognition, and also result in bowel problems,” he said. “Some cases end up in the hospital as a result of these iatrogenic complications.”
Mukhamad S. Valid
Nonoperative treatment is a bridging act for a patient suffering from long-term spinal pain, Mukhamad S. Valid, MD, told Spine Surgery Today. It is important for a patient with these long-term difficulties to manage their pain, receive the treatment they deserve, and get back to a semblance of their old life, but it is also important to monitor a patient’s long-term response to opioid use and any possible complications they may be developing, he said.
“The purpose of using opioids in chronic painful conditions is improvement of quality of life through effective pain control so the patient can resume his or her previous functional role as soon as possible,” Valid said. “Opioids can be used as long as benefit outweighs risk.”
The quick decision to prescribe opioids for a patient suffering from spinal pain, according to Devin, is one of the overall problems with the medication. Instead of first looking to other pain modalities to help a patient, he said he believes the physician’s decision to prescribe an opioid and let the patient go along their way has become too prevalent in the practice of pain management.
Treatments in place of opioids
Opioids are one of the most commonly prescribed and favored medications and methods of treatment for patients suffering from chronic back pain, Valid said.
“On the other hand, back pain is one of the most common, most burdensome and costliest health care problems draining the American health care system. The management of back pain usually starts conservatively with painkillers, nonsteroidal anti-inflammatory drugs and physical therapy. If conservative therapy fails within a few months to control the pain and return the patient to his or her baseline, surgery becomes the unavoidable option,” he said.
Devin said physicians and surgeons should first consider prescribing anti-inflammatories, anti-convulsants and antidepressants to patients with long-term spine pain. These pain modalities can achieve the same result as an opioid without the potential complications and addictions that some patients develop, Devin said.
“Therapy — strengthening of the core — that is an alternative that can give a patient a long-term solution to their problems. That is what will give the results in the long run. An injection, a quick fix, it might not work. If you are running a marathon you are going to need strengthening or conditioning. You do not get a quick result from something else,” Devin said. “The problem with opioids is people can have a hyperalgesic response, it starts to become upregulated. The neuroreceptor becomes upregulated, and that is how they develop a tolerance to opioids.”
Acceptable short term solution
These upregulated neuroreceptors then make a patient experience more pain from motions or activities that previously did not affect them, Devin said.
Clinton James Devin
“A small stimulus, just a little movement, now causes pain. What these people really need to do is get off of it. The opioid makes them feel normal, but it does not make them feel better. It is just their baseline. That is the problem with chronic opioid use in long term conditions. It will make someone’s pain worse,” he said.
McGirt agreed, and said the use of opioids for conditions such as herniated discs or disc instability should be viewed as “band aids” and a means to bridge the gap between intense pain and long-term durable solutions.
“I think opioids are very efficacious in the short term, but they have drawbacks, such as dependency, as well as tolerance, so they are not great longterm solutions. They are used in long- term chronic pain management, but it is a medicine that is over utilized and abused,” he said. “It is one that does have a role in acute pain management. It can be helpful, obviously, in folks who have other medically refractory pain symptoms.”
Finding that sweet spot is important, but it can be difficult, according to McGirt. If a physician prolongs a patient’s treatment with the medication, and the patient eventually does have to have surgery for a long-term problem, he said it can actually decrease the level of improvement from the surgical intervention.
While Kahn agreed that the use of opioids for chronic spinal issues is a difficult issue, he said it is often left up to how the patient responds to non-opiate medications and how they react to the opiate medications. Kahn has had patients on opiate medications for decades who do not show signs of addiction or dependence and who use the opioids responsibly to improve their chronic spinal pain conditions.
Monitoring use is critical
When a patient responds well to an opioid and it brings them back to their baseline, it is a “home run,” Kahn said. However, physicians have a responsibility to monitor their patients and to monitor their long-term reactions to the medication. It comes down to the patient, over time, having a functional and an analgesic response to opioids, he said.
“Can they do more activity with the meds than without the meds? Does that outweigh the side effects they may have? Are they showing any kinds of addiction? Are they using the meds faster and faster? Are they losing their script every month? Are they coming every 2 weeks for a refill instead of every 4 weeks? If all of the signs are good that they are using the meds responsibly without escalating doses and without signs of abuse, and if they are having a good analgesic response, a good functional response, and no addictive responses, then it is a ‘home run.’ These are the patients you want to select for long-term use of opiates,” Kahn said.
In the right setting, with the right controls, you can have safe, long-term pain management with opiates, he said.
However, physicians have tools to help them counteract a dependence on opioids and monitor a patient’s opioid use. Devin typically has his patients sign a document that sets out the details of their treatment with the medication.
“I have patients sign a ‘pain contract.’ You will need opioids after surgery, but you are (the physician) going to need to come up with a plan of how to come off of them and taper off of them over time, so it is not a surprise to the patient when you pull the rug out from them,” Devin said.
New York program
Additionally, in New York, the state instituted the I-Stop/Prescription Monitoring Program, Kahn said, which was developed to curtail individuals from abusing opiates and other pharmaceuticals. Put into action on Aug. 27, 2013, the online program requires all physicians in New York to consult the database before prescribing for Schedule II, III, and IV controlled substances, which includes opiates. In addition, after prescribing one of the medications, the physician must upload the patient’s information into the database.
This new database makes it more difficult for a participant who abuses opioids to gather several prescriptions for the medications at once, and it also helps a physician monitor just how often a patient is refilling his or her opioid script. The database provides real time monitoring for pharmacists and physicians and has improved safeguards for the distribution of the medications, according to Kahn.
“The FDA does have certain requirements, as well, but New York State has more stringent requirements,” Kahn said of the I-Stop program. “It is mostly done for opiates, so a physician has to check whether a patient is getting multiple scripts or using multiple pharmacies.”
Lipetz, who also practices in New York, lauded the effectiveness of the I-Stop program, as well. He said there have been several cases in the past year, he said, of his practice being notified by the program for patients receiving opioid prescriptions from numerous physicians at once. Before the program was instituted, the staff at Lipetz’s practice would not have been aware of these patients receiving several prescriptions.
“I would say, of all the electronic record keeping that we have been mandated to use and partake in, the I-Stop is one of the smartest and one of the most useful we have,” Lipetz said.
Knowledge can be powerful
Even though opioids are useful in the management of spine conditions and can certainly help patients deal with crippling pain, Lipetz has found that knowledge can often be just as valuable as medication for some patients.
“I think that, in general, we tend to over medicinalize spinal pain presentations. Often these are benign and short-lived conditions. If we educate patients to the origin of their symptoms, assure them they are not in imminent danger, that goes a long way in healing, as well,” he said. “If we focused on education, rehabilitation, and a little less on prescribing of medication, we would do our patients a great service and help them through their episodes. An educated patient is much more likely to heal physically and emotionally than one who was just prescribed medications,” Lipetz said. – by Robert Linnehan
References:
Catan T. A Pain-Drug Champion has Second Thoughts. The Wall Street Journal. Dec. 2012. http://online.wsj.com/news/articles/SB10001424127887324478304578173342657044604. Accessed Aug. 26, 2014.Centers for Disease Control and Prevention. CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. Jan. 13, 2012. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm. Accessed Aug. 13, 2014.
Portenoy RK. Pain. 1986;25:171-186.
For more information:
Clinton James Devin, MD, can be reached at 500 Northcrest Dr., Suite 501, Springfield, TN 37172; email: clinton.j.devin@vanderbilt.edu.Stuart B. Kahn, MD, can be reached at Department of Orthopedics, Mount Sinai Medical School/School of Medicine, 5 East 98th St., Box 1188, New York, NY 10029; email: stuart.kahn@mountsinai.org.
Jason S. Lipetz, MD, can be reached at 801 Merrick Ave., East Meadow, NY 11554; email: jlipetz@lispinemed.com.
Matthew J. McGirt, MD, can be reached at Carolina Neurosurgery & Spine Associates, 225 Bladwin Ave. Charlotte NC 28204; email: matt.mcgirt@cnsa.com.
Mukhamad S. Valid, MD, can be reached at the Kingsbrook Jewish Medical Center, 585 Schenectady Ave., New York, NY 11203; email: mswalid@yahoo.com.
Disclosures: McGirt is a consultant for DePuy Synthes. Devin, Kahn, Lipetz and Valid have no relevant financial disclosures.
What is the role of opioids in the nonoperative treatment of chronic spine problems?
Joe Sam Robinson
Opioids are overused
The therapeutic and diagnostic dilemmas imposed upon the American health care apparatus by the vagaries of lumbar spine difficulties have provoked a general overuse of opioids. All too often patients are started on and continue to take opioids before a diagnosis is discovered and more conservative therapeutic modalities are employed; thus, rendering later, more appropriate treatments less successful. Most lumbar spine problems can be managed with minimalistic conservative modalities, such as physical therapy, bracing and anti-inflammatory medications. Impingement on neuronal structures can often be dealt with by diminished activity, bed rest and gabapentin. Additionally, appropriate use of anxiolytics and antidepressive medication can play a role in maximizing a return to normality. When and if surgery becomes necessary (again, as minimalistic as is feasible), transient use of opioids is justifiable. Problems, however, occur when patients develop long-standing and persistent back, hip and leg complaints following failed conservative therapy and operative intervention. Many patients at this point are treated with increasing doses of opioids.
The concomitant side effects of such therapies are unfortunate, and a substantial degree of opiate dependence ensues. In light of such difficulties other therapeutic modalities might be considered, such as morphine pumps and spinal cord stimulation.
In my opinion, chronic use of opioids should be reserved for patients who have exhausted every other modality of therapy, and who have substantially reduced life expectancy and/or ability to comfortably ambulate.
Joe Sam Robinson, MD, is a professor and chief of neurosurgery at Mercer University School of Medicine and a Clinical Professor at Georgia Regents University, Macon, Ga.
Disclosure: Robinson has no relevant financial disclosures.
Michael J. Vives
A reasonable, but sometimes difficult treatment option
A low, stable dose of opioid medication may be a reasonable option for selected patients with chronic spine problems. There are logistical issues, however, that make it difficult for spine surgeons to take on that role for nonoperative patients on an indefinite basis. Surgeons have limited time in the office since much of their time is spent in the operating room and in the hospital managing their perioperative patients and seeing consults. Their schedules can be unpredictable due to emergencies and on-call responsibilities. Joe Sam Robinson
Taking on the role of providing opioids on a chronic regular basis for even well selected, nonoperative patients opens up another whole dimension to a practice that may overburden the surgeon. I tend to enlist the help of the patient’s primary physician or a pain specialist in such situations, so that they can see the patient on the regular basis necessary for the treatment to be safe and the patient to be compliant with prescribing recommendations. I will see the patient at longer intervals or on an as-needed basis if their symptoms worsen.
Michael J. Vives, MD, is an associate professor and chief of the spine division in the Department of Orthopedics at Rutgers New Jersey Medical School, in Newark, N.J.
Disclosure: Vives has no relevant financial disclosures.