We asked a few experts to share what they see as the biggest trend shaping how healthcare providers approach the management of patients’ pain.
An estimated 20 percent of American adults live with chronic pain.
This type of pain has frequently been linked to a variety of physical and mental conditions, and helps to drive up healthcare costs while decreasing patients’ quality of life.
Treating a patient’s pain can sometimes be fairly simple.
Take a patient with a herniated disc, who’s experiencing pain radiating down the leg as a result of nerve root irritation. Physical therapy and/or an epidural steroid injection will oftentimes provide a patient with relief from this type of pain.
Helping a patient manage his or her pain isn’t always as straightforward, however, and has historically involved a variety of methods such as interventional procedures, physical therapy, medication management and much more.
Pain management techniques are always evolving, and with this in mind, we asked a few experts to weigh in with what they see as the trends currently shaping how healthcare providers approach the management of their patients’ pain.
Moving away from medications and invasive surgery
Medications such as opioids and surgery have traditionally been tried as frontline treatments, says Dawood Sayed, MD, division chief of pain medicine at the University of Kansas Health System.
“What we are seeing now is that minimally invasive pain treatments like spinal cord stimulation are moving more frontline,” says Sayed, who is also president of the American Society of Pain and Neuroscience.
“These treatments are given early on, when patients experience pain instead of using surgery and medications upfront. These are moving up the treatment algorithm as a frontline therapy.”
Indeed, opioids will always play a critical role in the management of acute pain, according to Barbara St. Marie, PhD, AGPCNP, assistant professor in the College of Nursing at the University of Iowa.
“The challenge is to address urgent needs to relieve patients’ pain while preventing misuse and reducing incidents of opioid use disorder,” wrote St. Marie in a 2019 piece for AACN Advanced Critical Care.
“Patients who are prescribed opioids are increasingly concerned with the risks of using them, and healthcare providers need to be ready to answer their questions.”
Trending toward Data and Evidence-based Therapies
As the pain management field has developed from a model relying on the administration of steroid injections and medications such as opioids as frontline pain treatments, new therapies continue to come to market backed by solid evidence and data, says Sayed.
“This is a positive trend for the field,” says Sayed. The shift in spinal cord stimulation started, he adds, with the 2016 publication of what Sayed describes as “the first big randomized controlled trial” in spinal cord stimulation in more than 20 years.
“This changed the game, because having solid evidence and data inspired physicians to adopt these new treatments. This happened in other specialties, such as cardiology, oncology and orthopedics years ago, but evidence was not as widely available in the pain field for many years. This has now shifted.”
CBD Proves to be Useful
Ryan Douglas, founder of cannabis consulting firm Ryan Douglas Cultivation, sees cannabidiol (CBD) taking its place as a viable pain management tool.
CBD is a naturally occurring compound found in hemp and cannabis plants, and has proven useful for management of the pain associated with migraine headaches and arthritis, for example, but minus the psychoactive high that comes with using cannabis, and with a low likelihood of negative side effects.
“It can also be obtained without a doctor’s prescription. In states where recreational cannabis is legal, dispensaries sell a vast array of products with CBD as the active ingredient. In states without cannabis dispensaries, CBD products can be found in pharmacies, health food stores or purchased online,” says Douglas, adding that tetrahydrocannabinol (THC) is also increasing in popularity as a method of pain management prescribed for back, muscle and joint pain.
“THC is an appealing natural alternative for people suffering from pain who do not want to take synthetically-produced pharmaceutical drugs.”
Minimally Invasive Spine Surgeries and Procedures Emerge
Historically, a herniated disc or spinal stenosis meant surgery for a patient.
“But we’ve seen great outcomes from newer, minimally invasive techniques that are performed primarily by interventionalists on an outpatient basis, such as low-profile spinal implants and SI joint fusion using a minimally invasive approach,” says Sayed, adding that many lower back pain cases can be treated with minimally invasive pain treatments.
“When you look at how cardiac disease was managed 15 to 20 years ago, and you see how interventional cardiology transformed care to be less invasive and more effective, we are seeing a similar thing happening in spinal disease with minimally invasive techniques. Patients gravitate toward minimally invasive techniques, and we are seeing good outcomes.”
Innovation Takes Off in Neuromodulation and Spinal Cord Stimulation
An “innovation explosion” began with the landmark SENZA RCT study, says Dr. Sayed, adding that this 2015 research “really pushed all the other technologies in spinal cord stimulation to up their game with level data.”
Sayed singles out Nevro’s Senza Omnia platform as an example of a leader in this space, noting that the system uses 10hz of stimulation, but can also pair 10kHz with other waveforms such as Burst and low frequency for more challenging pain.
“Increased versatility in treatment platforms is a major advancement, and there is so much more to be learned,” says Sayed. “Increased versatility in treatment platforms is a major advancement, and there is so much more to be learned. In the future we can explore even higher frequencies than 10khz, and there’s still room for improvement as the technology continues to advance.”
An Exciting Trend Around the Corner
Ultimately, Sayed is optimistic that the possibility of combining all of these treatments is on the horizon.
“For example, we can combine treatment for a patient with nerve pain and osteoarthritis pain in the spine,” he says, “with spinal cord stimulation for the nerve pain and a minimally invasive spine treatment for the arthritis. We can combine these treatments in a low-profile, minimally invasive way.”
References
- Dahlhamer J, Lucas J, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults—United States, 2016. Morbidity and Mortality Weekly Report, Sept. 14, 2018.[https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm]
- St. Marie B. Assessing Patients’ Risk for Opioid Use Disorder. AACN Advanced Critical Care. Volume 30, Issue 4, Winter 2019. [https://aacnjournals.org/aacnacconline/article-abstract/30/4/343/30602/Assessing-Patients-Risk-for-Opioid-Use-Disorder?redirectedFrom=fulltext]
- Kapural L, Yu C, et al. Comparison of 10-kHz High-Frequency and Traditional Low-Frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain: 24-Month Results From a Multicenter, Randomized, Controlled Pivotal Trial. Neurosurgery, 2019. [https://s24.q4cdn.com/932612397/files/doc_downloads/outcomes/Comparison_of_10_kHz_High_Frequency_and.97253.pdf]
- Kapural L, Yu C, et al. Novel 10-kHz High-frequency Therapy (HF10 Therapy) Is Superior to Traditional Low-frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain: The SENZA-RCT Randomized Controlled Trial. Anesthesiology, 2015. [https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2411790]
SIDEBAR
Safe Care for Patients at Risk of Opioid Abuse
While opioids can be very useful in managing patients’ pain, they come with a risk for misuse.
In a recent issue of AACN Advanced Critical Care, Barbara St. Marie, PhD, AGPCNP, assistant professor in the College of Nursing at the University of Iowa, offers a few strategies to ensure safe care for patients who are discharged from the hospital in pain and considered to be at high risk. For example:
- Designate a responsible person who has been vetted as a reliable caregiver to be in charge of opioid medications, with comprehensive instructions for safe use.
- Order a computerized lockbox for the medication and arrange for them to be dispensed on a predetermined schedule.
- Transfer the patient to a transitional care unit where opioid medications can be administered for short-term pain management while the patient is recovering from illness or injury.
- Determine whether pain can be managed effectively with nonopioid medications and nonpharmacological interventions.
Reference
- St. Marie B. Assessing Patients’ Risk for Opioid Use Disorder. AACN Advanced Critical Care. Volume 30, Issue 4, Winter 2019. [https://www.aacn.org/newsroom/opioid-use-disorder-adds-to-pain-management-challenges]
