Pain clinic offers alternatives to opioids

Jan. 10--As the opioid epidemic continues to tighten its grip on the United States, and physicians increasingly are encouraged to curb opioid painkiller prescriptions, chronic pain sufferers are being referred to pain clinics in the hopes their pain can be alleviated through non-opioid-based treatments.

Nationally, opioid deaths have quadrupled since 1999. Iowa isn't immune. According to the Iowa Medical Association, the state's rate of opioid deaths has more than tripled over the past 10 years.

Because of the growing epidemic, the U.S. Centers for Disease Control and Prevention have issued stricter opioid prescribing guidelines with lower dosage recommendations and more specified recommendations on monitoring and discontinuing painkillers. It also has extended safety precautions to be applied to all patients instead of just those considered to be high risk.

Opioid prescriptions hit their peak in 2010, when there were 81.2 prescriptions per 100 people in the U.S. That number has decreased since then, albeit slowly, and in 2015 there were 70.6 prescriptions per 100 people. It's still three times higher than opioid prescription rates in Europe.

"(CDC) guidelines have just been ratcheted way down," said John Dooley, an American Board of Anesthesiology-certified pain management physician who practices at Pain Centers of Iowa clinics in Burlington, Coralville and Davenport. "So now a lot of doctors are faced with the fact that they already have patients that exceed guidelines."

The Pain Centers of Iowa, located in the same office as the Iowa Bone Care Center at 903 Oak St., is one of three pain clinics in the Burlington area. Dooley and Jeff Juhl of Rushmore Pain & Medicine Inc. are among the only board-certified pain management specialists in the area. Physical therapy, chiropractic and acupuncture also work to treat pain.

"The community here has not had access to specialized pain management care," Dooley said. "I mean, you have radiologists doing it. They're radiologists. They don't practice pain. You have CRNAs doing it at the hospital. They're nurses. You have anesthesiologists doing it, but they don't specialize in pain. And that's about it here."

Though not an effective or sustainable long-term treatment method, opioids long have been prescribed for chronic pain. People who have been taking the medication for long periods of time build up a tolerance to the drug, meaning they require a higher dosage for it to have the same effects.

"What our effort really is directed at here is to get people off of opioids because they're only a short-term treatment plan," Dooley said. "They don't last forever because of the development of a tolerance where the drug stops working."

That's not to say all patients taking prescription opioids are immediately cut off, or cut off at all. Some patients may continue taking their prescriptions following an in-depth assessment

"We try to reduce the dose to the lowest possible amount, such as that they continue to function as opposed to just having it unsupervised and just giving them large numbers of pills," Dooley said.

He estimated about 60 percent of the patients he sees are able to get off of pain medications by switching to alternative methods that target the root cause of the pain.

Among those techniques is targeted injections of anti-inflammatories and nerve blockers in cases of specific, acute pain.

If injection methods don't work, problem nerves can be burned into submission with radiofrequency ablation. Burning the end of the nerve prevents it from transmitting messages to the brain.

Another pain treatment method is through an intrathecal pump, which involves inserting a catheter into the spinal column. The catheter then is hooked to a pump implanted underneath the skin. That pump then directs a small amount of medicine to a targeted spot.

"It's hard for the patient to get to it because it's in a pump," Dooley said. "The patient can still get at it, but not very many of them do."

The most successful of the pain treatment methods, however, is spinal cord stimulation.

"Eighty percent of those patients, we get off of pain medicine," Dooley said.

With spinal cord stimulation, pain is replaced with pleasant vibrations. This is accomplished by inserting small wires down the spinal column. The wires are connected to a small computer that sends electricity along the wires.

"The beauty of that technology is that we can trial it," Dooley said.

Before the wires are surgically implanted, patients try it for seven days. Leads are inserted and taped to their back. At the end of the seven days, the patient decides whether it decreases their pain, makes them better able to function or both.

If the trial is successful and the patient decides they want the implant, it will be surgically implanted. After an operating room can be secured, that is.

Dooley and Michael Hendricks, a retired orthopedic surgeon, are trying to establish an ambulatory surgery center in the area where the procedures could be performed without having to wait for an operating room, but so far have been unable to obtain the required Certificate of Need from the Iowa Department of Public Health.

According to data from the Department of Human Services, 7,708 Des Moines County residents, or about 19 percent of the county's population, received Medicaid in November, the most recent data available. The state average per county is 4,628 people.

For whatever reason, the CDC has found "inappropriate prescribing practices and opioid prescribing rates are substantially higher among Medicaid patients than among privately insured patients."

Luckily, both insurance and Medicaid cover non-opioid-based treatments.

"Insurance covers it because it works," Dooley said.

In addition to alternative pain management techniques, people also can lessen their pain by increasing activity in their relaxation and motivational centers. A good way to do this is by swimming or walking for 45 minutes at the same time every day.

"You grow the motivation center, you grow the relaxation center, they take away circuitry from the pain processor, and then pain diminishes," Dooley said.

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