New treatments for chronic pain available

John was a laborer, working in a warehouse, performing heavy, physical work. A simple task, one he had performed on a daily basis, caused him to twist his back in such a way that pain shot down his leg. Treatment included a prescription for physical therapy and a back brace, as well as a pain reliever, although he found, over time, he needed more of the medication to get relief.

In contrast, Tim worked in an office, sitting at a computer console, endlessly typing away at his keyboard. Sounds like an easy task, but not when his elbow was killing him. He was a recreational hockey player, which is where he suffered a hard shot, sending him crashing into the boards. His arm was wrenched in the process, producing significant pain in the limb. The ER doctor had said it wasn’t broken, but his discomfort was intense.

Susan had suffered from a sore hip for years, so she believed the hip replacement would be a blessing. The surgeon said everything went according to plan and she left the hospital as scheduled. Surprisingly, her post-operative pain was severe and didn’t let up in the ensuing weeks.

What do these people all have in common? They had pain treated with opioid medications, a class of drug that includes hydrocodone, morphine, heroin, and other derivatives of opium. These drugs work by binding to pain receptors in the nervous system, thus blocking pain signals. As a result, this type of drug is prescribed to treat severe pain that doesn’t respond to other types of pain relievers. But how often are other drugs, non-narcotic medications, used prior to the dispensing of an opioid? And are they being prescribed for the appropriate types of pain?

Estimates state approximately 8 percent of patients prescribed narcotics will become addicted. It used to be somewhat difficult to obtain opioids to treat pain, but that changed in the 1990s when new opioids became available (eg Oxycontin, with its aggressive marketing campaign staged by the manufacturer). Unfortunately, the prescribing of opioid drugs became the default method of treatment for pain, even when there were better alternatives. Physicians were given inaccurate information about the addictive potential of this class of medication, and the opioid crisis resulted. Yet these drugs don’t actually address the physiologic mechanisms of pain and have never been studied in longer clinical trials.

After about 64,000 opioid-overdose deaths in 2016, the US government declared a national public health emergency. The consequences of the opioid epidemic have been devastating. The number of deaths from opioid overdoses in the United States in 2014 was calculated at about 50 a day. This is more than three times the number in 2001. This, of course, does not even touch on the number of individuals who became addicted to painkillers and turned to heroin to satisfy their addiction.

Over the years, opioids indeed became the “go-to” choice for all manner of pain. But addiction is not the only negative consequence of this class of drug. Other side effects are well known, including sedation, slowed breathing and other respiratory issues, constipation, nausea, and some cardiovascular disorders. Central nervous system side effects are also common, like impaired concentration, confusion, sleep and memory problems. These are not rare, with estimates revealing about 80% of opioid users experiencing at least one of these.

Pain is a tremendous and widespread problem. It affects more people than diabetes, heart disease and cancer combined. But pain does serve an important biologic function, warning an individual the body is in danger. While acute and chronic pain can have similar effects on both physical and mental well-being, their origins are different, and thus, they should be treated differently. The former is typically the result of some form of trauma, be it an accident (like being checked into the boards) or from some type of medical treatment (having a major joint replaced).

Although acute pain tends to resolve within a month or two, it certainly is capable of producing physical and psychological consequences. Perhaps the one of most concern is the progression to chronic pain, one reason it is critically important to treat acute pain promptly and adequately. With early and appropriate intervention, acute pain can generally be relieved successfully.

Chronic pain is pain that persists for longer than 12 weeks. When pain signals in the nervous system keep firing for an excessive length of time, significant physical, emotional, and social disability often occur. One hundred million people in the US, 1.5 billion people worldwide, suffer from the often life-altering effects of chronic pain.

Medicine is in dire need of better drugs for pain relief, particularly non-opioid drugs. Research continues into new options. One drug currently in development acts not on nerve cells but on macrophages, a cell type important in immunity. This particular compound, which also acts to lower blood pressure, does not cross the blood-brain barrier, eliminating many of the complications associated with traditional narcotics such as concerns of addiction. It may also be an excellent option for neuropathic pain.

Numerous studies have been performed in recent years on the use of CBD products. CBD stands for cannabidiol, one of the two primary components of the marijuana plant. CBD has no psychoactive or euphoric properties but, apparently, provides some important medicinal benefits. How many positives there are, we are only beginning to discover. The medicinal attributes of CBD are apparently due to the presence of the endocannabinoid receptor system, which receives and translates signals from cannabinoids. The human body produces some cannabinoids of its own, termed endocannabinoids. This system helps to regulate such functions as pain, sleep and the immune system.

CBD has become a popular form of treatment for pain management. It seems to be so effective that an increasing number of doctors have been recommending it. A recent study focused on the treatment of fibromyalgia with CBD, and the results were very promising. The participants saw a significant reduction in their symptoms and overall measures of pain when compared with traditional methods.

Scientists have also been evaluating the use of CBD for the treatment of multiple sclerosis. CBD appears to reverse inflammatory responses and produce an improvement in motor skills. The use of CBD for the treatment of epilepsy in children has recently made the headlines, and the benefits warrant further study. Further evidence of the therapeutic gains possible with CBD products include a reduction in opioid consumption. This is apparent in those states which have legalized marijuana, either medicinal or recreational.

All in all, there have been well over 20,000 published scientific articles on cannabinoids and their related effects on all sorts of medical ailments. CBD products may become an essential component of a physician’s armamentarium, the means by which we treat chronic pain. Unfortunately, at the present time, these products may not have the quantity of CBD claimed since they are not evaluated by the FDA. The best chance is to look for third-party certification.

It’s not easy living with pain. Whether you suffer from muscle spasms, arthritis, or any form of chronic pain, finding a solution to your pain can mean the difference between a pleasant day and a nightmare of a day. Historically, holistic methods of pain relief have not been sufficiently utilized, since prescribing an opioid has been easy. But the pendulum has swung hard in the other direction. Still, we don’t have sufficient alternatives for the treatment of pain. Short term use of an opioid is currently a successful method of treating acute discomfort. The picture becomes much cloudier when it comes to the treatment of chronic pain. As is true for many topics regarding modern medicine, more research, and more options, are needed.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.