Originally published on WorkersCompensation.com’s Experts View on May 4, 2020
Healthcare is complicated. Healthcare delivered as part of a workers’ compensation claim is even more complicated, for manifold reasons. But stakeholders often do not act as that’s the case because they look for a simple solution to complex problems. For those with the problem (in this case, an injured worker with a medical condition) or for those trying to treat it or deciding what to pay for, looking for a simplified solution is often not the right answer.
Qualifying as a proposed simplified solution to a complex problem…prescription painkillers to treat chronic pain.
Most everyone in the United States at this point has heard about the opioid epidemic. Most people realize it started with the over-prescribing of opioids for all types of pain in the mid-1990s. Only those truly educated on the subject realize it has evolved from prescription opioids to heroin to illicit synthetic fentanyl and carfentanil as the primary cause of overdose and death. That same educated stakeholder has likely also paid attention to federal (CDC Guideline for Prescribing Opioids for Chronic Pain in 2016), state (e.g. Florida’s Chapter 2018-13 that limits opioid prescriptions to a 3-day supply for acute pain) and work comp (e.g. New York’s drug formulary that became effective on December 5, 2019) changes that have dramatically influenced prescribing behavior.
The recognition of prescription opioid overuse has created a zealous open market of alternatives that all want to take on the mantle of THE opioid alternative. That includes other pills like gabapentin (common namebrand of Neurontin) and pregabalin (common namebrand of Lyrica). Both are considered off-label (i.e. the FDA has not explicitly approved their use) for treating chronic pain. Both have been in the Top 10 of cost and utilization in work comp for at least the past decade and their upward trend correlates with the downward trend of opioids. But both have such a high possibility of abuse that they are being increasingly added as controlled substances in states (gabapentin in Kentucky, Michigan, Tennessee, Virginia, West Virginia) and countries (both gabapentin and pregabalin in the United Kingdom). Then there are NSAIDs (dangerous side effects if used long-term) and benzodiazepines (even more addictive and difficult to wean than opioids) that are often included in a polypharmacy regimen to treat pain. Then add medical cannabis to the mix, whose momentum in acceptance across the country continues unabated (e.g. medical marijuana is the lawful tool in Illinois used for the “Opioid Alternative Pilot Program” launched on January 31, 2019).
Not that opioid or gabapentin or pregabalin or NSAID or benzodiazepine or muscle relaxant or antidepressant pills are always inappropriate in treating chronic pain. The FDA approved them for a reason, and when their benefits exceed the risks with manageable side effects they are often approved by treatment guidelines. But the expectation that is set – said and unsaid – is often that pills by themselves can be the solution and THE alternative to opioids. But it doesn’t stop there.
Beyond pills there are TENS units and spinal cord stimulators, acupuncture and dry needling, physical therapy and chiropractic, biofeedback and virtual reality, cognitive behavioral therapy and motivational interviewing, gym memberships and nutritional training. There are TV and radio commercials for over-the-counter products that talk about how they can solve pain, with some even referencing the “opioid epidemic” as a reason to try their product. The Internet is filled with testimonials. The list is (almost literally) endless. Many of these are valuable and helpful, with growing scientific proof (or sometimes just marketing promises) of their effectiveness.
But which one is THE opioid alternative for chronic pain?
The short answer is it could be any of them. The full answer is the appropriate solution depends upon this individual with this specific condition at this specific time. The deep answer is that only a customized bio-psycho-social-spiritual treatment approach that takes into account the whole person – including THE most important tool in pain management, the brain and its neuroplasticity that can change how pain signals are processed – yields long-term successful outcomes. In other words, there is not a single – or simple – solution that works for everybody. There is a solution – likely a mixture of tools – for an individual that may need to change along with their condition over time. And that is because when there is a complicated problem, there is never a simple solution. Just like the reasons for the pain, the effective management of that pain is complex and individualized and the toolbox needs to be full.