Alternative Therapy for the Management of Chronic Pain

Andrea Eisenberg, MD

What non-opioid alternatives are available for the management of chronic pain?

For years, opioids were the "go-to" drugs for managing pain, including chronic pain. But over time, we've seen how opioids cause more harm than good and increase the risk of abuse and overdose over time.

In his lecture "Alternative Therapy for Management of Chronic Pain," now available for CME credit through AudioDigest, Dr. Michael Lang discusses alternative therapies for the management of chronic pain.

Common chronic pain complaints

There are many health issues that cause chronic pain, but Dr. Lang highlights the most common. They are:

• Back pain: The majority of patients with this complaint will improve over time. Dr. Lang recommends starting with an antidepressant first and then possibly adding an anti-convulsant.
• Peripheral neuropathy: This may require higher doses of antidepressants or anti-convulsants. It may need to be titrated slowly.
• Fibromyalgia: Some believe this is really a disorder of major depression that presents somatically and that these patients have a lower threshold for pain, leading to dysfunction. Because of this, medications or interventions that help raise patients' pain threshold, such as bupropion or exercise therapy, are most helpful.
• Headaches: Usually, there's a vascular and neurological base to the symptoms of those who complain of headaches, and both need to be addressed. Opioids have no role in management of headaches.

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Medication alternatives to opioids for chronic pain

In his lecture, Dr. Lang discusses several pain medications we can prescribe as alternatives to opioids.

Psychiatric medications

This is the first option you should consider. Most patients with chronic pain have issues with sleep and mood changes that harm their quality of life and can even lead to them becoming nonfunctional. The cycle must be broken. Focusing on the depression first is usually most helpful, since depression can hypersensitize you to pain.

Medications that target both serotonin and norepinephrine receptors rather than just serotonin receptors are most effective. When you prescribe those medications, you target both the pain response as well as the mood/depression reaction. Some examples are:

• Tricyclic antidepressants: This class is the most effective for chronic pain because it offers an analgesic effect as well as targeting mood changes, which helps reduce the pain response. These work well for pain related to fibromyalgia, migraines and peripheral neuropathies. However, problems can arise if you increase dosage to manage symptoms, including an increased risk of anti-cholinergic side effects, including dry mouth, dry eyes and blurry vision. You also have to be careful not to overdose these patients, which can be fatal (there's no such problem with SSRIs).
• Cymbalta: This medication targets serotonin and norepinephrine equally. It works best for back and shoulder pain, but there may be gastrointestinal issues with increasing doses.
• Effexor: This medication targets serotonin receptors first, then norepinephrine at higher doses. Because of this, it's just like using an SSRI at lower doses, and it's not effective for chronic pain. Patients need to be slowly titrated to higher doses to avoid anxiety that may arise when the norepinephrine receptors are targeted.

Anti-Convulsants

Another family of drugs to consider in the management of chronic pain are anti-convulsants. This line of medications targets overactive nerves by stabilizing them and blocking the firing of higher-frequency nerves. Most agents need higher doses to work well, and it takes time to dose these patients adequately and avoid side effects. Because of this, patients need to be educated beforehand so they have appropriate expectations for results. This family of medication works well for peripheral neuropathies.

Topical Agents

Most topical agents have the advantage of avoiding systemic side effects. However, Dr. Lang notes that there have been studies showing the topical agent Voltaren may increase liver enzymes and shouldn't be used for chronic pain. Alternatively, you can monitor the patient's liver enzymes.

Non-drug treatments for chronic pain

There are many alternatives for managing chronic pain that don't involve medication at all. That said, using them takes time and valuing them requires a cultural shift in how we think about managing chronic pain.

• TENS units: These use electrical impulses to modulate nerve firing and can be found in drugstores. One study comparing TENS units to a placebo for nerve pain found no improvement over the placebo, but it may have a huge psychological benefit.
• Physical therapy, exercise therapy and acupuncture: Although PT and related treatments have been shown to have many benefits, insurance coverage can be a challenge.
• Tai chi or yoga: Dr. Lang prefers tai chi because it doesn't rely on holding poses like yoga does, which may be difficult for patients with chronic pain.
• Chiropractic medicine: Dr. Lang discusses a study of patients with chronic neck pain. After spinal manipulation, there was 100% reduction in pain in 52 weeks. For the proper patient, this may be a reasonable treatment.
• Behavioral medicine: Cognitive behavioral therapy changes how the patient thinks about pain and has been shown to decrease need for pain meds. Dr. Lang encourages practitioners to have patients evaluated by a behavioral therapist prior to starting any pain medications. Another strategy is "acceptance and commitment," which teaches patients to come to terms that they have pain but learn to modify their lifestyle in order to minimize the pain.
• Interventional approaches: This is the use of epidurals, which optimally helps those with herniated discs and joint injections. However, these can only be used a few times a year and have limited duration of improvement.

Dr. Lang concludes his lecture with a stepwise approach to addressing chronic pain in which opioids are a last resort. Overall, he believes that we need to rethink the concept of pain. Rather than using pain scales, we should evaluate how a patient is functioning and put the emphasis of treatment on improving a patient's daily function.