| One-Minute Clinician

Denouncing Opioid Use...but What to Use Instead?

The hot topic with respect to practitioner groups is there seems to be a lot of denouncing of the fact that there’s too much opioid use and everyone is looking for ideas to minimize these opioids. But one of the top suggestions that people will consider is maybe nonopioid and nonpharmacologic treatments, which is fine. The problem that we have is everyone is overlooking the main problem: how do you address the problem that the patient’s in for. Many times there is an alternative option, and we can step back, take a different look at the clinical picture, find an interesting way of handling that patient to come up with more appropriate clinical diagnosis, and maybe alter the treatment so that you can minimize the need to prescribe an opiate or other medication to begin with. There are so many patients where we have done nothing different except to take a step backwards, re-evaluate the patient from an entirely new perspective, come up with a new work and clinical diagnosis and then treat a problem to resolution that somebody was managing for chronic pain for often years without resolution. I don’t necessarily think we have to look for new means of treatments but we have to look for better ways of triaging the treatments that we have.

No, not every patient is going to respond to every single treatment. The problem is we group things together like back pain as a single entity when back pain itself is a symptom not a diagnosis. So the diagnosis should be, let’s say, facet-mediated back pain which might be an inflammatory pathology when we should recognize that that same inflammatory pathology with respect to the facet joint might inflame a nerve root causing a radiculitis. So then the most effective treatment would be to somehow control the inflammation of the nerve root and the facet joint so that we can treat it to resolve it. Why do we have to mask the pain or overshoot the problem by let’s say injecting a facet joint and “Ooh that didn’t work,” but you missed part of the problem. So you came back a few weeks later we did a transforaminal epidural and while by that time the facets reinflamed then we feel like it’s the dog chasing its tail.

There were other times where it could be something as simple as a patient is overtreated. Some of these patients are on multiple medications by multiple providers for multiple problems because everybody is looking at the patient from the perspective of their own specialty which is very narrow and focused and sometimes the patients don’t even link the pieces together and they’re trying to treat each problem as if it’s independent. How many antidepressant medications do we have that also bleed over into the pain community? If we can modulate or influence the system by putting these patients on these medications which is what we’re doing because we’re influencing them, we’re really not controlling them. How do you know that that anxiety medication is not going to play a role in what that patient’s perception of pain is? We’ve seen so many patients that all you literally have to do is address the medication profile they’re on for another disease state and all of a sudden their pain issues resolved.

So the question is I think a little bit different. It’s basically, how do we center our care or create more of a patient-centered model, which I think would improve our outcomes to begin with.Then we can be a little bit more careful with respect to the care that we’re providing a patient.