Three physicians, who practice in different medical specialties and provide care for patients with chronic neck pain, spoke with SpineUniverse about opioids for pain management. Our experts are spine surgeon Todd J. Albert, MD, physiatrist Gerard Malanga, MD, and pain medicine specialist Neel Mehta, MD.
This is a continuation of our article, Opioids for Chronic Neck Pain: Continue or Taper the Dose?. Our experts provide additional and important insights into Lisa’s opioid use to manage her chronic neck pain.
Lisa is a 56-year-old office manager at a legal firm. Three years ago, she underwent an ACDF (anterior cervical discectomy and fusion) after a biking accident left her with severe nerve pain that radiated from her neck to her right fingertips. Lisa's surgery was successful, though her recovery was painful and took nearly a year. Two years after the completion of her recovery, she's still in pain daily, and her surgeon isn't convinced it's connected to her surgery. Lisa has taken opioid medication for her chronic pain, but her doctor has recommended reducing her dose, which makes Lisa worried about her ability to manage her pain.
Dr. Albert: Yes. I have had patients find success with acupuncture, hypnosis, and biofeedback. Therapies like heat and ultrasound have helped people find pain relief without drugs.
Dr. Malanga: There are numerous therapies that she can explore—and that’s what she needs to understand. From simple things like acupuncture, various vitamin supplements for nerve pain and inflammation (such as alpha lipoic acid and high-dose omega 3s) to more advanced treatments like electronic stimulation devices and cognitive-behavioral therapy.
I believe the mind-and-body approach is the most profound way to address pain. Cognitive-behavioral therapy has a large body of scientific evidence that supports its effectiveness. That’s where a pain psychologist or someone specializing in this method of treatment can be very helpful to change her perception and management of pain without the need for a pill.
Dr. Mehta: I’d want to revisit some therapies that have proven successful in reducing pain in other patients. These might include:
These therapies should also be exhausted before Lisa submits to a life of continuous opioid use.
Dr. Albert: I would tell her that this is not easy—I’d acknowledge it’s a difficult problem, and she’s not alone. The physician has to be in it with her, and she has to be committed to getting off her medication. Personally, I’ve seen many patients who have gone through this process, and I can reassure her that she will be better on the other side. In fact, when she’s off opioids, she may have no pain at all.
Dr. Malanga: That fear is actually causing more problems in and of itself, and that fear needs to be explored. What is she really afraid of—the pain, her ability to manage pain, or needing another surgery?
A lot of her fear stems from not knowing the other ways that she can ease her pain outside of taking medication. The fear of the unknown is probably the greatest fear. I would reduce her fear by giving her confidence that her pain can be well controlled, and her life with some pain can be better managed without medication.
Dr. Mehta: I’d let Lisa know that we will be partners in getting her life back. Lisa and I would communicate and see each other frequently through this process to help her feel supported—I wouldn’t just be there to refill her prescriptions over the phone.
I’d also help Lisa set realistic expectations. There may not be a point where she experiences zero pain, but functional things—like working or caring for herself—can be improved without the use of opioids.
Dr. Albert: There’s almost nothing that would necessitate a return to opioids—the exception being if she received a new diagnosis (pain in a different area or a completely new problem).
My best advice to anyone is that if you’ve never been on opioid medication, you should be skeptical of starting them. If your doctor recommends one, ask if there is a non-narcotic alternative to help manage your pain. From the patient’s perspective, it’s much easier never to start taking them in the first place.
Dr. Malanga: Under a physician’s supervision, there shouldn’t be a lot of issues during the weaning process. If she’s feeling jittery, has muscle pain, or gets diarrhea—those are withdrawal symptoms that can be managed with other medications or a slowing of her weaning process. If Lisa drops her dose slowly, it should not be an issue.
In my opinion, weaning is in the best interest of most patients (especially those who have not been on opioid medications for a long period of time), but there is a select group of patients who can be managed and get profound benefit from long-term opioid use. These patients have exhausted all other measures, but opioids have given them improved pain control AND improved daily function.
We currently live in an environment that believes everyone must be off opioids. However, the likely realty is that most people don’t need to be on them, but some patients can safely manage their pain on them when closely monitored by a physician.
Dr. Mehta: As miserable as it may be, reducing opioids and going through withdrawal isn’t life threatening. Lisa may experience flu-like symptoms, diarrhea, cramps, and sweating—but rest assured, these all will pass. Fortunately, people tend to tolerate opioid reduction well. However, if Lisa experiences a big spike in pain, or if she’s unable to get out of bed, I’d want to know about it and certainly do what I can to support her.