Edith German struggled with back pain for years, thanks to a family legacy of arthritis and some other issues.
She tried injections and had surgery a decade ago. But one trouble spot persisted, sending pain shooting from the top of her hip down to her foot. With it went her ability to garden at her Bellevue home and to stroll the boardwalk at nearby Fontenelle Forest.
Seeking a solution, Dr. Thomas Brooks in March threaded spaghetti-like insulated wires alongside her spinal cord and tucked a small, flat metal box under the skin of her back.
The box sends high-frequency electrical pulses through the wires and to her spinal cord. It’s believed to interrupt the transmission of pain signals to the brain and thereby reduce pain.
For German, 84, the spinal cord stimulator is working. She recently walked a mile on the forest boardwalk and is easing back into yard work.
“I’m doing great,” German said. “It’s like a miracle cure, because I have had back pain forever.”
German isn’t alone in her struggle. In the United States, some 25.3 million or an estimated 11 percent of adults report daily or chronic pain. Some people — at least 5 million, by one estimate — use opioids for long-term pain management. But while opioids can be very effective in controlling acute pain from injury or surgery, research indicates they don’t work that well for chronic pain that lasts longer than three months. And they also pose a risk of addiction.
As the country walks back from a more liberal use of narcotic painkillers and the resulting opioid crisis, doctors and patients face another challenge — finding alternative therapies that are effective, accessible and affordable.
Pain experts say interventions like the one that’s helping German, as well as tools including physical therapy, exercise and counseling, must be part of the solution.
“There is a whole host of options we can provide for our patients that has nothing to do with a pill,” said Brooks, a pain medicine specialist with Nebraska Medicine’s Pain Medicine Clinic.
Some caution, however, that opioids shouldn’t be cut out altogether. Scaling back too quickly could leave some patients, including those who are stable on long-term opioid regimens, in the lurch.
Compounding the challenge, no one thing works for everyone. “That’s why we really need a broad spectrum of therapies available to help people with pain,” said Dr. Kenneth Follett, a neurosurgeon at Nebraska Medicine and past president of the American Academy of Pain Medicine.
Recognizing the need for options, the National Institutes of Health last week announced a new research program aimed at enhancing pain management and improving treatments for opioid misuse and addiction.
“It comes down to balance,” Follett said. “We need to be mindful of the issue of opioid misuse, and we have to be mindful of the need for pain control.”
He and others also urge more education about pain and how it works, both for clinicians and patients. That includes the seemingly harsh lesson that it may not be possible to entirely eliminate pain.
“What our goal should be is to get your level of function to a point where you can live a normal life,” said Dr. Thomas Tape, a Nebraska Medicine physician and chair emeritus of the board of regents of the American College of Physicians.
Follett said pain treatment is generally incremental, with patients first caring for their own pain and then seeking help from a primary care provider. If that doesn’t work, patients may seek a specialist.
Brooks and other pain specialists can use a number of interventions, from injecting steroids into joints to implanting spinal cord stimulators.
Until recently, Robert Graybeal of Omaha took daily opioid medications to manage pain that started with a back injury he suffered at work in 1990.
This spring, however, Graybeal got a spinal cord stimulator. He, like German, is working back up to walking greater distances, with no more tingling and pain down his legs.
“I actually feel like I’m doing something, getting better finally,” he said.
Brooks said the devices have been available since the 1960s and did a good job for limb pain. But recent improvements are producing outstanding results for a range of conditions, low back, limb, neck and even chest pain. They cost about $50,000, including a test drive-like trial to check effectiveness. They typically are covered by insurance, he said, but he has had to battle with insurers for some newer indications, such as neck and chest pain.
Brooks said treating Graybeal involved working through and finding solutions for a number of issues. Patients with chronic back pain, in particular, often have multiple sources of pain. One problem can lead to others. Sorting through them all takes a consistent approach.
“Frequently, there is no quick fix,” Brooks said.
Other options include steroids, epidurals to calm irritated nerves and nerve ablation, Brooks said. That procedure typically provides relief for six months, sometimes up to two years.
Health care providers also continue to explore ways to manage pain — and limit opioid use — upfront.
Some surgeons and anesthesiologists have adopted protocols aimed at limiting narcotic use during and after surgery. A few orthopedists and pain specialists have begun using supercooled needles to temporarily knock out peripheral nerves in knees, not only to speed recovery and reduce painkiller use after knee replacement surgery but also to provide temporary arthritis pain relief. And some oral surgeons have begun injecting a slow-release, non-narcotic painkiller into the jaws of teens having their wisdom teeth extracted.
Dr. Stephen Coffey, an oral surgeon with Oral Surgery Associates in Omaha, said his early follow-up indicates that most young patients who got the slow-release painkiller, called Exparel, didn’t fill their prescriptions for opioids. Those who did took only one or two of the eight pills he now prescribes.
Limiting youths’ exposure to opioids is important, he said, given research indicating that those who’ve used the drugs to treat acute pain are more likely to use them recreationally later on.
Dr. Joshua Urban, an orthopedic surgeon with OrthoNebraska in Omaha who specializes in knee and hip replacements, said his informal number-crunching so far indicates that patients who get the cold treatment, called iovera, before a knee replacement take half the opioids after surgery and spend half the usual time in the hospital.
He and others also are exploring using iovera in other parts of the body and for other types of pain.
Efforts to curb prescribing of opioids have been underway for several years, prompted by the recognition nationally that prescription drugs were contributing to overdose deaths.
The Centers for Disease Control and Prevention in 2016 advised that physicians first look to non-drug approaches, such as physical therapy, and medications like aspirin and ibuprofen, with the exception of cancer and end-of-life care.
Following the CDC guidelines, some pharmacy chains and insurers have tightened prescription policies. Most include limiting first-time prescriptions for patients new to the drugs to a seven-day supply. Medicare recently set prescription limits for users beginning in 2019.
Nebraska historically has not had as big a problem with opioid addiction as some harder-hit states. State officials, however, have taken a number of steps to keep the state from following suit, including rolling out their own pain guidance document with the Nebraska Medical Association.
A new Nebraska law that takes effect this summer sets a seven-day limit on opioid prescriptions for minors, with some exceptions. It also requires people picking up opioid prescriptions to show valid identification. Doctors and other prescribers will be required to warn patients getting opioid prescriptions about the dangers of addiction.
Such measures appear to be having an impact. Opioid prescriptions nationwide declined 22 percent between 2013 and 2017, according to a recent American Medical Association report. The volume of opioids prescribed dropped 12 percent in 2017 alone, the biggest annual drop in more than 25 years.
Tape, also chief of general internal medicine at the University of Nebraska Medical Center, agreed that campaigns to raise awareness about opioid-related concerns are proving successful. More and more of his patients are saying they don’t want them. But it will take some time for everyone — patients and prescribers — to catch up.
Experts say simply reducing patients’ use of the medications won’t be enough. They need something to replace them, a concern recently echoed by the American Medical Association. That means making sure patients can get those other therapies and that they’re covered by insurers and other payers, including Medicaid and Medicare. And concern remains for the millions who don’t have insurance.
Treating pain is expensive, costing the United States an estimated $560 million to $635 million a year, according to the National Academy of Medicine.
Dr. John Massey, a Lincoln pain management physician, said opioids are cheaper upfront. Other solutions may be more costly initially but can prove cost effective in the long run.
“What we’re saying is find the treatment that’s most effective,” said Massey, who served as chairman of the task force that wrote the Nebraska pain guidance. “And surprise, in general, more often than most people think” it’s not opioids.
Massey said insurers and other payers generally are covering other treatments, although it may require doctors to first demonstrate that it is the best option.
Both Blue Cross Blue Shield of Nebraska and Nebraska Medicaid cover physical therapy and chiropractic treatments, officials said. Thomas “Rocky” Thompson, deputy state Medicaid director, said the state continuously monitors its benefits package to see what else may be needed.
But some patients have tried and failed other therapies. Some can’t take other medications. For those few, Tape said, chronic opioid therapy may be an option. With it, however, come a host of safeguards.
Tape said patients on long-term opioid regimens where he practices at Nebraska Medicine’s Midtown Clinic have to take classes to learn about pain co-taught by a behavioral health expert and a pharmacist. Patients learn about non-medication strategies to treat chronic pain, including how thoughts and feelings can impact it. They also learn coping skills and keep pain logs to track how medications and other interventions, such as having a massage, affect it.
Ruth Maher, an assistant professor in Creighton University School of Pharmacy and Health Professions, said future clinicians will need to be able to teach patients about their pain, from its complex biology to the psychosocial factors that contribute to it. Creighton two years ago added a separate, required course on pain to its physical therapy program, said Maher, who holds a doctorate in physical therapy.
Given the variability in how each person responds to pain, Maher said, the future of pain management lies in personalized care plans.
Said Massey, the Lincoln physician, “Fundamentally, it has to be good patient care and helping people understand that all these things that seem less medical are critical.”