Doctors try new strategies to relieve pain without addiction

Managing pain in an era when society’s sharp focus is on addiction to opioids was hard enough. Managing the addiction that too often follows was tougher. The COVID-19 pandemic just added to the challenge.

Opioids — substances that act on certain of the body’s receptors — can provide welcome pain relief. But their misuse and overuse have generated some startling and tragic statistics in Colorado, where 3,089,898 opioid prescriptions were dispensed in 2019, an average of more than 8,000 a day.

Colorado has seen about 16,000 overdose-related deaths since 2000, including 1,457 in 2020, up from 1,062 the previous year. Those statistics include a 783% increase in Fentanyl-related deaths between 2017 and 2020. 

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“Fentanyl is much stronger and obviously more lethal than your standard narcotic pain medication,” said Heather Ihrig, a registered nurse who directs Evans-based CO-SLAW, which stands for Colorado Opioid Synergy for Larimer and Weld. “Unfortunately in our community, we’re finding it laced in a lot of medications. Folks think they’re taking something else but it contains Fentanyl, and that’s why we’re thinking [it] accounts for a lot of the real huge spike in overdoses. It’s laced in other pain medications, it’s laced in some street marijuana, and even some Tylenol and Advil. They think they’re taking something for pain they got from a friend, and it actually contains Fentanyl.”

Dr. George Girardi, who practices at UCHealth facilities in Fort Collins and Loveland, said pain management can include a “spectrum of care, from giving drugs to other alternatives.

“Once we can identify what the pain generator is, there’s interventional procedures we can use,” he said. “We can burn nerves, there’s spinal-cord stimulators, epidural steroid injections. We try to avoid using as much medication as possible.

“Acute pain opioids are still a very viable option,” he said. “For example when you break your leg, you’re going to have pain for a period of time, and it’s very reasonable to give that patient opioids. Where the concern with opioids comes in is more the chronic symptoms that don’t necessarily get better, so how do you manage them?”

Girardi said physicians have done a good job of navigating pain management in the COVID-19 era.

“A lot of the patients who have chronic painful conditions tend to be elderly and more at risk of COVID, so bringing those patients in has been a challenge,” he said. “But there’s a lot we can do over telehealth — for example, somebody who has leg pain and I have their MRI scan. It’s not optimal to not examine the patient, but a lot of times I can say, ‘Well, your pain from your history is coming from the L5-S1 level, your MRI shows a clear disc herniation there, so let’s bring you in and do an injection at that level.’”

New federal regulations have helped on the monetizing side as well, he said.

“Prior to COVID, it was difficult to be reimbursed for phone calls and telehealth visits,” Girardi said. “They’ve changed some of those laws now. Obviously, we have to generate some revenue to keep our office open, and now we’ve been able to legally bill for that time spent.”

CO-SLAW supports a network of clinics that offer medication-assisted treatment and counseling services. The clinics have care coordinators and case managers, Narcan education and kits at no charge, support for family members and loved ones, and — since June 2020 — expanded services to cover all types of substance-use disorder.

The Food and Drug Administration has approved medication-assisted treatment to address opioid addiction, a dependence on prescription painkillers such as Vicodin, Oxycontin, Percocet and other drugs such as Fentanyl and heroin. Three FDA-approved medications to manage pain and addiction include Buphenorphine or Suboxone, Naltrexone or Vivitrol, and methadone.

Medication-assisted treatment “gives them the opportunity to get their lives in check so they can go back to becoming a functioning member of society, hold a job, get their kids back, etc.,” Ihrig said. “That in conjunction with behavioral counseling has been beneficial.”

CO-SLAW’s “Empowered Relief” program, Ihrig said, “works in group settings with folks to restructure how they respond to pain.” She said CO-SLAW also serves as a resource for physicians prescribing pain medications, through Dr. Lesley Brooks, its medical director.

“Opioids are still needed for acute pain,” Ihrig said, “but for long-term use they’ve been shown to have highly addictive properties.”

To help head off that addiction, she said, hospital-based physicians have been releasing patients with no more than a three- to seven-day supply of opioids, adding that “it all depends on the individual; it’s more to do with brain chemistry and science.”

New research is even calling opioids’ efficacy in pain relief into question.

Linda Watkins, a professor of psychology and behavioral neurosciences at the University of Colorado Boulder, discovered in her lab in 2018 that taking the drugs too early after surgery can actually magnify pain. “It interacts with the pain itself and causes the whole chronic pain problem to become much worse,” Watkins said.

Treatment for the aftermath of addiction is crucial, Ihrig said. “Our position is when it is identified that they have a potential misuse or abuse of narcotic pain medications, how do we get them access to treatment so they aren’t having to go through withdrawals — especially with  individuals who have been on chronic pain medications for a long time.

“Without these things, you see a relapse rate of 90%,” Ihrig said. “With them, it’s down to 40%.

“Providers are becoming a lot less likely to prescribe,” she said, “so we’re trying to find alternatives.”

The threat of lawsuits increasingly is driving those provider decisions, but also has led to a new framework that may offer some help for those treatment programs.

On Aug. 26, Colorado Attorney General Phil Weiser and local government leaders unveiled a joint framework for distributing more than $400 million that the state stands to receive from litigation settlements to address the opioid crisis.

“The joint framework is structured according to a memorandum of understanding between the Colorado Department of Law and all counties, municipalities, towns, and county and city municipal corporations that agree to the framework even if they have not filed lawsuits against opioid manufacturers, drug distributors, or others for their role in creating and fueling the opioid epidemic,” said Weiser’s office in a media release. “All participants in the framework must use the funds they receive for opioid-abatement purposes such as drug treatment, recovery, prevention and education, and appropriate harm reduction programs, as well as addressing the epidemic’s impact on the criminal-justice system.”

The framework organizes the state into 19 regions, with 60% of opioid settlement proceeds allocated to these regions. The regional collaboratives, according to the release, “will have their own governing boards composed of public officials from local governments in the region, will conduct their own needs assessments, and will develop community-specific plans for spending the funds they receive for opioid abatement programs.”

Local governments will get 20% of the opioid settlement proceeds, another 10% will go to an infrastructure fund for capacity building in hard-hit regions that lack adequate facilities for treatment and recovery services, and Weiser’s office will manage the remaining 10% to address statewide concerns.

The state will receive maximum payments if most local governments support the plan by Jan. 2. According to Weiser’s office, Colorado stands to receive more than $400 million from opioid settlements announced to date including $300 million from Johnson & Johnson and its drug distributors, $10 million from McKinsey & Co., $75 million from Purdue Pharma and the Sackler family and $25 million from Mallinckrodt.