Alternatives to Opioids in Chronic Pain

At the 2017 WCRI Annual Issues and Research Conference, a panel discussed alternatives to opioids in chronic pain. The panel included:

• Kathy Fisher – WCRI (moderator)
• Dean Hashimoto, MD – MA Department of Industrial Accidents
• Paul Sighinolfi – ME Workers’ Compensation Board
• Paul Tauriello – CO Division of Workers’ Compensation
• Dawn Ehde, MD – University of Washington School of Medicine, Dept of Rehabilitation Medicine

Marijuana

In January 2017, the National Academies of Sciences, Engineering and Health published a comprehensive report of the issue of marijuana as a medical treatment option. They reviewed available evidence regarding the therapeutic value of marijuana and arrived at 100 research conclusions categorized by the weight of the evidence. They also provided recommendations to improve research quality in this area. The report indicated there was conclusive or substantial support that marijuana resulted in improvement for chronic pain. But they also noted an increased risk for motor vehicle accidents and the development of major psychiatric illnesses. In addition, they pointed out there is little known about doses, routes of administration or side effects for commercially available marijuana products.

Two recent studies showed a 18-25% decrease in opioid deaths in states that passed medical marijuana legislation. EDITORS NOTE: I would question the causal relationship of this decrease in deaths to marijuana laws given the significant attention being given to reducing opioid prescriptions.

On of the biggest obstacle to marijuana as a medical treatment is the fact that it is still a Schedule I drug under DEA classification – meaning it has no legitimate medical use. That means the marijuana business is essentially “cash only” because the dispensaries cannot utilize the federal banking system, including credit cards. Other obstacles include that marijuana is not allowed under state treatment guidelines. Also some states have restricted coverage for medical marijuana under insurance policies. Colorado, which was ground zero in terms of legalization of recreational marijuana, prohibits payment for this under insurance based on current regulation.

Thus far, California, New Mexico, Maine, Massachusetts and New Jersey have allowed medical marijuana. This has gone the furthest in New Mexico, where there was a series of cases requiring carriers to reimburse for medical marijuana. New Mexico is currently developing a fee schedule and dosage standards for medical marijuana because of these court decisions.

There are some who make the argument that marijuana would be better than opioids because it is not addictive, has less side effects, and also has lower costs when compared to opioids. Others argue that medical marijuana is unproven and that without further study you cannot accurately access its effectiveness as a treatment nor the long-term side effects of its use.

Non-Pharmacological Alternatives for Pain Management

Exercise

What costs nothing, has no long-term adverse side effects, and has been proven to decrease chronic pain? Exercise. Physical activity is usually helpful in managing pain and preventing disability. These exercise programs need to be customized for the individual to account for their physician limitations but they can be very effective if the injured worker is diligent with them.

Cognitive Behavioral Therapy (CBT)

CBT is the prevailing type of pain self management. It is based on the cognitive theory, which is how we think impacts how we feel and function. Common elements of cognitive behavioral programs include relaxation training, cognitive therapy (changing unhelpful thinking) and behavioral strategies, including developing coping skills. There are many different techniques that can be included in CBT. Studies shown the magnitude of pain relief from CBT are similar to medications and certain medical procedures.

Mindfulness Training

Mindfulness meditation involves paying attention, on purpose, non-judgmentally, in the present moment. Mindfulness-based treatment is comparable in effectiveness to CBT. Both mindfulness and CBT can be delivered one-on-one or in group interventions. They can be classes or self help.