Back pain is one of the most common ailments chronic pain patients face. For some, a neurosurgical approach can offer much relief and may be an alternative to long-term opioid therapy. Here’s what one neurosurgeon and member of the AMA Task Force to Reduce Prescription Opioid Abuse had to say about treating patients with chronic pain and the Task Force’s efforts to end the opioid overdose epidemic.
Treating chronic back pain in neurosurgery
Jennifer Sweet, MD, is a neurosurgeon at University Hospitals Case Medical Center in Cleveland and the physician representative for the American Association of Neurological Surgeons on the AMA Task Force to Reduce Prescription Opioid Abuse. Dr. Sweet sees patients with chronic pain who have what is called failed back surgery syndrome.
“When patients are referred to me they’ve had big spine fusions and they’re still not getting better,” she said. “If patients don’t tolerate systemic opioids, or if high-dose opioids still don’t manage their pain, then I can offer another option. Interventions such as intrathecal pain pumps can provide the pain relief patients need, without all the side effects of systemic opioids.
“While this has traditionally been reserved for patients with cancer pain,” she said, “we are now realizing the potential benefit for chronic pain patients without terminal disease.”
The intrathecal pain pump delivers opioids locally to the area where the patient is experience pain through the spinal fluid. “It helps them get off the systemic opioids so they have less chance for addiction and less of the side effects,” Dr. Sweet said. “Over the last five years, it has become increasingly common to utilize these therapies for patients with isolated back pain from Failed Back Surgery Syndrome and even for neuropathic pain.”
“I don’t think it’s going to solve the major opioid epidemic,” she said, “but it may help treat patients who are truly debilitated by their pain, who have few alternative options.”
“I also see a big opportunity to really re-introduce into our pain management treatment algorithm other non-opioid medications, such as anti-inflammatory agents, antidepressants and anti-epileptics," Dr. Sweet said. "There are many more drugs available than just opioids, and a multimodal approach may represent another key strategy.”
Most of the patients Dr. Sweet sees want to get off of their pain medications. “They’re scared that they can’t get the pain medications easily, it’s becoming more and more difficult,” she said. “Their quality of life is not enjoyable and they don’t like the side effects.”
“If we determine the intrathecal pain pump is the best option, we do a trial and if they benefit from the trial we’ll implant the intrathecal pump in a small outpatient procedure,” she said. “All patients also must see a pain psychologist, and we will often refer patients to an addiction specialist when necessary to manage any physical or psychological opioid dependency or other co-occurring issue.”
“For the right patient, neuromodulatory approaches such as intrathecal pain pumps can be life-changing,” Dr. Sweet said.
Dr. Sweet talks Task Force, prevention and education
Nationwide there are many efforts underway to combat the opioid epidemic from all angles. The AMA Task Force to Reduce Prescription Opioid Abuse has been in this fight for several years, enlisting the help of physician members who are working to end the epidemic through several goals.
“The task force has been addressing a lot of important things,” she said. “First of all, getting physicians to register with their prescription drug monitoring programs (PDMP) so that we can look up patients, and every time we prescribe opioids we are documenting that so that other physicians can see who’s prescribing, how much and when.”
“We’re also trying to sort out the difference between a chronic type of pain, like the back pain patients that I see, versus an acute pain which would be when we prescribe opioids postoperatively,” she said. “Are there other types of medications that can be administered or other treatment options? So education is a tremendous focus of the task force.”
Another important effort the task force has made is “getting the message out there that legislation needs to change to increase naloxone availability,” Dr. Sweet said. “Also, it’s important to have greater access to addiction specialists in the community ready to treat these patients.”
“One of the areas where I think the biggest changes need to occur is in physician education,” she said. “And one of the ways we can do this is by teaching young physicians who are in their residencies that there are other options besides just opioids, although opioids do have their place in reducing pain, that there are other medications and that can help in prevention.”
”We have a lot of work to do,” she said, “and neurosurgeons are very glad to help the task force’s efforts efforts in prevention, education and advocating for patients.”