Commentary: Alternative to Opioids – A Pain Doctor’s Perspective

When someone comes to the emergency room with a broken arm – we call the orthopedic surgeon and put them in a cast. When someone comes in with chest pain – we call a cardiologist and treat that person for a heart attack. When a child comes in with an asthma attack – we call the pediatrician and give them an inhaler. But when someone comes in with pain, suddenly we forget how to be doctors. We forget our training to look for the problem and treat it at the source. Instead we cover up the problem with “harmless” pain pills and move on to the next patient feeling satisfied. The unfortunate reflex for most doctors when they hear complaints of pain is to simply write a prescription for narcotic pain medications.

In medical school, our only exposure to pain management is a half-day lecture, at most, on opioid medications. We learn how long they last, how they are metabolized and how strong one is compared to another. So when we encounter someone in pain, we simply write off one of these medications and move on because that is the limit of our training. However, for those of us trained in interventional pain management, we are taught to use narcotic pain medications only when absolutely necessary.

Taking narcotics for pain is no different than putting a Band-Aid on a bullet wound – the real problem is deeper and as long as it stays there, the problem will never go away. Pain management is meant to focus on treating the problem at the source. This does not always mean finding the problem and being able to fix it, but rather focusing the treatment at the area that matters. For example, if the pain is due to a disc herniation causing inflammation in the spine – we will perform an epidural to deliver small amounts of cortisone directly at the area that is inflamed, thus focusing the treatment only on the area in need. If the pain is coming from the joints in the neck (the facets) – we will perform a diagnostic nerve block first to confirm the location(s) and use radiofrequency ablation to stun those nerves and prevent them from sending painful signals to the brain.

We can perform procedures like these virtually anywhere in the body for nearly every type of pain. More advanced types of treatment like spinal cord stimulators send signals to block the pain through wires inserted near the spine. They are similar to pacemakers where small wires go into the heart to send electrical signals to get it to beat correctly. We can use this to block some of the most intense types of pain: complex regional pain syndrome, neuropathy, sciatica, pain after surgery, arachnoiditis and even headaches.

In other cases of more widespread pain, we can utilize something known as infusion therapy. Using a variety of different medications ranging from magnesium to ketamine, we can treat syndromes like fibromyalgia, facial pain, neuropathy and even depression. In more extreme cases, we use a pain pump to administer incredibly small amounts of medication to treat pain at the level of the spinal cord, which blocks pain at the source. One of the medications in particular we can use in this pump is Ziconotide – a purified sea snail toxin that blocks pain receptors inside the central nervous system. Even more impressive is the fact that not a single person has ever died from this medication. Not even Tylenol can make that claim.

There are more than enough alternatives to opioids when treating pain and pain management specialists are trained to work with patients to offer these solutions. When someone has a toothache, they call a dentist. Anyone can pull out a tooth but a dentist has been trained to handle it properly. The same can be said for any medical ailment, and pain is no different. Other specialties have a basic understanding of pain and that certain medications can mask it. But their understanding of pain is the same as mine of a root canal – I am sure I could perform one if I had to based on my understanding of anatomy, but others would be better suited to handle it because of their training.

Corey W. Hunter MD
The Ainsworth Institute of Pain Management