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Interventional Alternatives to Opioids in Pain Management

Tim J. Lamer, MD
Tim J. Lamer, MD walks us through the many, different interventional treatments for pain therapy as an alternative to curve the rising opioid epidemic.
8/23/2021
Pharmacology
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“Hello, I'm Dr. Tim Lamer. I'm a pain management specialist at the Mayo Clinic in Rochester, Minnesota, and a professor of anesthesiology. I work in both our pain medicine department as well as our multidisciplinary spine center. 

Today, I'm going to be talking about interventional alternatives to opioid therapy for pain. 

WHY DO WE NEED TO TALK ABOUT ALTERNATIVES FOR PAIN THERAPY? 

Well, obviously there is an opioid crisis in the country, and I would say really in the last 10 years, opioids have been overused for chronic pain. We need alternatives, and there are, in fact, many alternatives. In my practice, I seldom have to resort to opioids because we have many other options out there. 

We have rehabilitative options. We have other medications besides opioids. And we have our interventional options. 


WHAT DO INTERVENTIONAL OPTIONS ENTAIL?

So when we talk about rehabilitative options, we might be talking about things like physical therapy, exercise, heat, ice, things like that. When we talk about interventional options, we might be talking about acupuncture or massage therapy. 

In terms of categories, there are really three broad categories of interventional options: we've got regenerative options, injections or nerve block options, and neuromodulation. 


HOW CAN I DEFINE MY PATIENTS’ INTERVENTIONAL OPTIONS?

Examples of regenerative options would include platelet-rich plasma, also known as PRP therapy, stem cell therapy, stem cell injections, etc.

Nanoparticle therapy is one of the hot new topics for nerve blocks. We've also got thermal ablative options such as cryotherapy and radiofrequency ablations. 

Regenerative options are kind of a hot area in general. It's really popular primarily because so many celebrities have resorted to this treatment. Platelet-rich plasma therapy, PRP therapy, or PRP injections have all really received a lot of press because many professional athletes have had this treatment and have touted its success. 


WHAT IS PRP TREATMENT? 

In a nutshell, it's a treatment for musculoskeletal conditions, chronic muscle pain, chronic tendon pain or tendinopathies, and some chronic joint pain conditions. 

What we do is we take blood from the patient, spin it down or centrifuge it, and take out the platelet-rich fraction of that blood, which also has some growth factors in healing factors. Then we take that spun down a fraction, and we inject it to the target tissue, whether it might be a joint attendant or a muscle. 

We usually combine that with some activity modification of physical therapy. And ultimately we're hoping for tissue healing and pain improvement. 

WHAT TO KNOW ABOUT PRP THERAPY OR REGENERATIVE THERAPY

First of all, it's not FDA approved. What that means is that the treatment has gotten a little bit ahead of the science. And a lot of it, again, I think is pushed by the fact that so many celebrities have had this treatment. It's become very popular. 

There are some studies out there that have definitely indicated that PRP therapy may have some successes, especially in knee pain, and in some of the tendinopathies. But when we say it's not FDA approved, we can also say that, for the most part, insurance companies and especially government payers such as Medicare will not pay for the treatment. So the treatment will come out of the patient's pocket.


WHAT ABOUT INJECTIONS, NERVE BLOCKS, AND NERVE BLOCK THERAPIES?

When we talk about thermal ablative procedures, we're talking specifically about cryotherapy, cold therapy, or radiofrequency ablation, which is a heat therapy since radiofrequency ablation is most commonly done.

Basically, we're taking a small probe or a specialized needle, and we're placing it either near the target tissue that we're trying to treat or, more commonly, near a nerve that we're trying to block or ablate. This causes the temperature to increase usually to about 75-80 degrees centigrade and results in thermal destruction, either of the tissue or of the target nerve that we're treating.

And now we're actually applying the therapy to some other painful joints, such as hips and knees. The therapy has been around for many years, and like most treatments that have been around for many years, there've been many improvements. 

Some of the things to know and to tell patients, first of all, in one of the paradoxes of medicine, when a patient has a nerve injury, and we want the nerve to grow back, it often doesn't. 

In this particular case, when we intentionally ablate the nerve, we'd often prefer the nerve not to grow back, but it often does. I usually tell patients that the average duration of treatment is about nine months. Usually, they'll have to have this treatment done about once a year. Again, especially for low back pain, the success rate can be very high, and there are very low complication rates. 


FINAL INTERVENTIONAL OPTION: NEUROMODULATION THERAPY

So when we talk about neuromodulation, we're talking about delivering an electrical signal, basically an electrical therapy to a target nerve, spinal cord, or the brain. Neuromodulation really is one of the hottest and fastest-growing areas in medicine, and it's really exploded in the last 10 to 15 years. When we talk about neuromodulation for pain, we're usually talking about either spinal cord stimulation or peripheral nerve stimulation. 

There are some other types of neuromodulation techniques, but these are the most commonly used. Spinal cord stimulation has been around for a little over 30 years. And again, like most things in medicine, the therapy has improved greatly. 

Both the hardware and software platforms that we use for stimulation have improved greatly, especially in the five last 5 to 10 years, such that now, for properly selected patients, we're talking success rates in the 75% or greater range. The therapy itself involves placing a wire, or what we call an electrode array, next to the target tissue. 

Using a peripheral nerve or the spinal cord, that electrode array or wire is then connected to a battery. The way to think of it is that it's very much like a pacemaker. The battery is very much like a pacemaker generator. And the wire, instead of being connected to the heart, is connected to a target neural tissue, either the spinal cord or a nerve. Electrical impulses are then delivered to the target nerve or spinal cord, and the electrical signal basically blocks pain signals from being transmitted to the brain. 


WHO IS IN NEED OF NEUROMODULATION THERAPY?

Patients with bad diabetic neuropathy would be good candidates. And patients who have chronic nerve pain after injury, especially a condition called complex regional pain syndrome and properly selected patients, the success rate is very high. 

Obviously, it’s a very invasive treatment. These are surgically implanted devices. So they're certainly not first-line therapies, but on the other hand, there has been a faulty notion that these are really end-stage therapies. Again, the treatment success rates for these treatments are quite high in properly selected patients. I think in the past, we've probably waited too long in many cases to offer these therapies for patients. 


WHAT PATIENTS NEED INTERVENTIONAL THERAPIES? 

So we've talked a little bit about specific interventional therapies. Who are candidates in general? If I'm seeing a patient either in my pain practice or in my spine center practice, and I'm thinking about interventional therapies, asking myself a series of questions helps me decide if the patient is a candidate. 

The first thing I'm going to ask is, is there a specific diagnosis or a specific structure that I can target for an intervention? So, for example, if a patient comes in complaining of widespread or generalized pain, that patient most likely will not be a candidate for interventional therapy. We really need a specific diagnosis or a specific structure. 


SIGNS A PATIENT DOES OR DOESN’T NEED INTERVENTIONAL THERAPY

The next thing I look for is our psychosocial morbidities. Chronic pain, like many chronic conditions, oftentimes in those scenarios, patients have psychological comorbidities, depression, or anxiety, all are quite common. 

Depression and anxiety are certainly not contraindications. But what I'm looking for are patients who have their depression and or anxiety managed. If their depression or anxiety is really the overwhelming presenting feature, then I have that patient see one of my psychology or psychiatry colleagues first to get their depression and or anxiety managed before we can circle back and look at interventional options. 

And then finally, we look at the underlying medical condition. Some of the things that really affect what we can offer and whether or not we can do interventional therapy are the anticoagulation therapy Coumadin and some of the direct and acting anticoagulation agents. 

So if I'm thinking about a spinal cord stimulator as a therapy, and the patient is on Coumadin, I'm going to have to deal with that Coumadin. I can't just put that device in the patient's spine. 


WHAT OTHER FACTORS NEGATIVELY AFFECT THE TREATMENT?

Smoking is an issue. I won't do a surgical implant on a patient who is smoking. So we have to talk to the patient in that scenario about getting off of the tobacco for at least a few weeks to improve wound healing. 

Diabetes is another concern. If we're doing steroid injections, we'd like to see their blood sugar under control. And again, if we're thinking about surgical devices, we want to see their diabetes under control to mitigate infection concerns. 

The other biggie for us is immune-modulating medications. There are so many new immune-modulating medications on the market, both for rheumatic diseases as well as oncologic therapy, that these drugs are often a consideration for us. 

Again, not always contraindications, but drugs that we have to deal with, effects that we have to mitigate and think about as we offer therapy.”

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