Texas physicians explore alternatives to opioids for pain management
The opioid crisis continues to blur the lines between helpful and harmful for the people who suffer chronic pain and the physicians who try to help them.
“Unfortunately, the medical community is still not clear on why some patients have chronic pain and some don’t,” said San Antonio anesthesiologist Dr. Cannon Clifton.
While the reason for pain may be murky, the demand for relief is clear. Researchers in Texas are making progress with alternatives to opioids.
Alternative treatments
The opioid epidemic is ongoing and more lethal than ever, said Dr. Emanuel Husu, Baylor College of Medicine assistant professor, Ben Taub Department Physical Medicine & Rehabilitation.
The first wave was from 1999-2005, Husu said, marked by an increase in prescription opioid overdose deaths. The second wave, 2005-2011, was defined by an increase in heroin-related overdose deaths.
The third wave, which he said we are currently experiencing, shows a rise in synthetic opioid overdose deaths, such as fentanyl.
“This third wave is the deadliest of them all,” said Husu, who specializes in interventional pain management and addiction medicine.
This is not to say opioids don’t have a place in the arsenal of fighting chronic pain, Husu said, but it does generate more interest in alternative treatments, including conopeptides.
“One of the most special peptides comes from the spit of a snail,” said Husu, referring to the Conus magus, a predatory and venomous cone snail. “The snail might look cute, but it sticks out its tongue, covered in slime, and paralyzes the prey. There’s an entire space of research to find out what we can give to patients from the venom of animals.”
Conus magus conopeptide, or conotoxin, is administered into the spinal canal; multiple pokes are not required.
“We (at Baylor) put it into a pump that sits on top of the spinal cord,” Husu said. “The implant can stay there for the rest of the patient’s life. Every several months they get a refill of this peptide. Nurses can come and refill it from the comfort of the patient’s own home. It absolutely can revolutionize their life.”
Spring resident Shawn Bell, 52, was happy to get off fentanyl after what seems like a lifetime of chronic pain. Bell has been in a couple of serious car accidents, and that, along with a family history of degenerative disc disorder, has meant decades of surgeries, fusions, injections and opioid pain medications.
“I was really going downhill at a fast rate,” Bell said. “I was extremely lethargic. I had no desire to do anything, yet I had an extremely high-stress and responsible job. I would go to work every day and then come home, lay down in bed. Weekends, I never even got out of bed.”
Working closely with Husu, Bell found relief in a spinal cord stimulator that he charges wirelessly on a weekly basis.
“I tell him every time I see him that he has changed my life,” Bell said.*
Anti-inflammatory therapy
Another solution may be the new use of an old medication.
Ketamine, approved by the Food and Drug Administration in the 1970s for use as an anesthetic on battlefields, in emergency departments and in operating rooms, is available off-label for the treatment of chronic depression and post-traumatic stress disorder. It is now also an option for the treatment of chronic pain.
“It’s a super potent anti-inflammatory medicine — if not the most potent one,” Clifton said. “And pain is almost always associated with inflammation.” Most pain medicines are derivatives of morphine, which acts on the mu receptor, Clifton said. Ketamine targets a centrally acting receptor known as the NMDA receptor, which reduces the potential for abuse, dependency and addiction.
“It helps the body break out of a looping pain cycle,” Clifton said. “It helps new nerves regrow that now don’t have the memory or imprint saying ‘I’ve got chronic pain.’ Ketamine helps those new nerves grow quicker.” Ketamine has typically been delivered intravenously at ketamine clinics, but Texas-based company NeoPath Wellness is just weeks away from having it available as a nasal spray. That would mean no needle sticks, no long visits at a doctor’s office for infusions and the medication easily gets to where it needs to go.
“Existing nasal sprays, like Afrin, Nasonex, even saline, utilize a generic nasal spray device (tip), which has been clinically shown to deliver less than 6 percent of the drug to the target nasal regions that are required to optimize the effectiveness of the drug,” said Clifton, who is also a professional engineer and general manager of NeoPath.
NeoPath has patented an anatomically designed spray tip that allows for precision delivery of the ketamine, Clifton said.
This means higher efficacy with lower doses, which also means fewer side effects. The standard protocol is generally six treatments over the course of three weeks.
Another potential benefit of ketamine therapy may also deliver hope to patients who have found themselves caught in addiction while battling chronic pain.
“The jury is still out, but data suggests that ketamine therapy can start to help get patients off of narcotics,” Clifton said.
Enhanced surgical recovery
An important but sometimes overlooked aspect of pain management is access to a multidisciplinary team to holistically work with patients. That is a key component for hospitals and surgery centers within the HCA Gulf Coast Division.
Dr. Augusto Sepulveda, interim division chief medical officer of HCA Gulf Coast Division, said the division’s hospitals have recently implemented an Enhanced Surgical Recovery program to improve outcomes of pain management before, during and after surgical procedures.
“ESR is evidence-based and looks to research data,” Sepulveda said. “ESR may improve acute and long-term management of pain by preventing chronic post-surgical pain and reduces postoperative opioid consumption. We have been able to decrease the need for opioids by over 44 percent.”
The components of ESR, which can be tailored to meet individual patients’ needs, include patient education, goaldirected fluid therapy, multimodal pain management with minimal or no use of opioids, pre-op hydration and carb loading, mobilization shortly after surgery, and the creation of a multidisciplinary care team.
“It’s a very dynamic process, very standardized, and the patient is truly an active participant, which is what we really like about the program,” Sepulveda said.