Alternatives to Opioids in Pain Management

Drs. Joseph Walker and Durgadas Sakalkale portraits

Dr. Joseph Walker and Dr. Durgadas Sakalkale are physiatrists in the UConn Musculoskeletal Institute. (Portraits by Tina Encarnacion)

When it comes to pain management, particularly back and neck pain, narcotics are not the only option. We ask two UConn Health physiatrists — Dr. Joseph Walker and Dr. Durgadas Sakalkale — about the approaches they take in the UConn Musculoskeletal Institute.

(March 2023, Dr. Joseph Walker, Dr. Durgadas Sakalkale, Chris DeFrancesco)

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Chris: Many of the awful stories we hear about the opioid crisis start with an injury or a condition that leads to a dependence on pain killers. Today on the Pulse, we talk about potential alternatives when it comes to pain management.

This is the UConn Health Pulse, a podcast to help you get to know UConn Health and its people a little better, and hopefully leave you with some health information you’ll find useful.

I’m Chris DeFrancesco. Now when it comes to recovering from back surgery, for instance, narcotics can have a place in the discussion about pain managment. But of course they’re not the only option. So we’ve brought in some experts from the UConn Musculoskeletal Institute to tell us more.

Dr. Joseph Walker is a physiatrist at UConn Health. His specialty involves physical medicine and rehabilitation, with a focus on nonoperative management of back and neck pain. And Dr. Durgadas Sakalkale, also a physiatrist, an orthopedic surgeon by training, at UConn Health’s Musculoskeletal Institute. Thank you both for joining us.

Dr. Walker: Thank you, Chris.

Dr. Sakalkale: Thank you, Chris.

Chris: It seems like neck and spine are good places to start with the topic of pain management. So why don’t we start with which conditions are most likely to require some kind of pain management intervention?

Dr. Sakalkale: So back pain or neck pain is so common that 80% of the patients are going to have some part of back or neck pain at some time in their life. So it’s a very critical part of the pain spectrum. Those are the patients that we very commonly see for treatment of pain, and that’s what they present to us with that. And my further comments would be more geared towards management of these pain conditions, particularly with more focus on non-opiate or non-medicinal pain.

Chris: All right, so we’re going to dig into that in a few minutes. What are some examples specifically within the neck and back and spine type realm? Like things like sciatica?

Dr. Walker: Yeah, so with neck pain there’s a number of either musculoskeletal, the muscles, it could be the joints, a lot of times it can be the nerves that give the symptoms that a patient comes in with. They may have pain that just is localized to one side. They may have pain that radiates down into their arms. Each of those etiologies have different diagnoses. Those diagnoses can include what’s called cervical spondylosis. They may have cervical radiculopathy. They may have myofascial pain, which can be various causes of neck pain per se. For low back pain, it’s kind of the cousin. There are disk-related causes, there are joint-related causes, there are muscle-related causes. You mentioned sciatica. Sciatica actually is a general term. It just really means leg pain, but it takes specialists like at the Muscoloskeletal Institute that can denote, is that sciatica due to a hip issue? Is that sciatica due to a nerve issue? And that’s what brings a lot of patients here, the confusion of, is it my back? Is it a different structure that might be giving me my symptoms?

Chris: Now we’ve spoken with your colleagues in this room before about back surgery and spine surgery, and one of the messages that always comes out of those conversations is, not everything requires surgery to alleviate or to treat. So if folks are dealing with you, are they dealing with you before we get to the point of surgery, or are there also cases where you’re helping people recover from surgery and manage their pain from that?

Dr. Sakalkale: My focus and even Dr. Walker’s focus here has been treating those patients particularly before they end up having some sort of surgery. So it’s more conservative care before a surgery is required or a patient is being referred for that purpose. Sometimes we do see some patients after they have had their surgery and they have continued pain. After six months having their surgery, they still have continued pain, then yes, then they do come to us for continued procedural pain management if indicated.

Chris: All right. So let’s talk a little bit about the kinds of things that you do if opioids, narcotics, those types of pain killers are kind of off the table, or if we don’t want them on the table. What are the options left for people who are experiencing the types of pain from the conditions we were discussing?

Dr. Walker: So a key thing to remember is that you have acute pain, pain that happens if there might be an injury or pain that may happen suddenly for a short period of time. You have sub-acute pain, pain that has happened after that acute period of time. And then you have chronic. Chronic pain is mainly if you were to define it more than six months, three months period of time. So each of those categories of pain have different treatments targeted towards them.

So if it’s more of an acute process, you want to treat that inflammation. You want to reduce that inflammation, have the person possibly rest for a period of time, but you want to get them moving. Subacute pain, that’s after they’ve had that acute process and they’re — Let’s say they’re doing the movement. Let’s say they’re doing physical therapy and it hasn’t gotten better. That’s where Dr. Sakalkale and myself can definitely step in to try an intervention to get them over the hump so that they can continue with their movement therapy. Next, if a person’s in more of a chronic aspect of pain, that’s really the person that you want them to move. That’s the primary aspect. We do interventions to help that person, but the main thing is, on them, to get their selves moving.

A key piece on that as well is that sometimes movement can be hindered by fear, fear beliefs that a patient may have. So in addition to doing interventions, you want to have that person doing some form of home exercises or working with our great therapist that we have at the Musculoskeletal Institute.

Chris: Fear in terms of re aggravating or re-injuring?

Dr. Walker: It could be all of that, a fear of what might have happened in the past if they might have injured themselves, and a fear that might not happen at all. Our physical therapists are able to work with them to get them moving so that that fear cycle can be broken, so the chronic pain can lessen — might not eliminate it, but at least lessen it so that they can be more functional.

Chris: So when I wake up in the morning and I have a stiff neck, or it’s hard for me to get out of bed because I’ve got some pain in my lower back, which category does that fall into? Is that subacute?

Dr. Walker: It depends. A lot of times for yourself per se, you may have had that achy, nagging neck that you might have noticed, but it might have reached a period of time where you have that crick and it becomes more of a painful process. In that moment, it might be an acute aspect and you might need an anti-inflammatory to take. You might need to work with a therapist to kind of get that mobility back, right? Once that acute period is over, then you may have some type of maintenance process that may help you in the long run.

Dr. Sakalkale: So in general, if your pain is six months or less duration, then we call it acute or subacute. But if it is lingers on beyond that time, then this falls into chronic category. And so the treatment approaches also differ a little bit in terms of how we treat those from the get-go.

Chris: I would love to hear a little more detail about what specifically we can do to treat pain. We did the breakdown of acute, subacute, and chronic, and the approach is going to depend on which category that falls in. So let’s say it’s acute. We’ll start with that. What are the kinds of things that you would help someone manage that pain?

Dr. Walker: A lot of times it’s an inflammatory process. So if we were to break it down, nonsteroidal anti-inflammatories might be a medication choice for that person, barring any side effects or any contraindications. Over-the-counters for that may include ibuprofen, might include Aleve, might include Motrin. Those are key anti-inflammatories. The other aspect is you want to treat what’s called the nociceptive part of pain, and that’s the sharp, spontaneous pain that may happen. That instance, a person may use Tylenol to help calm that down. In that acute aspect of using that combination of medications, that person may go into physical therapy. If it’s neck pain, and let’s say they’re having what’s called radicular symptoms, pain going down the arm, they may get traction as a modality.

Same thing for the lower back. They may get traction for that modality. If the person has back pain, some physical therapists, a lot of them nowadays, use what’s called a McKenzie technique, where they may direct the patient towards a certain movement-based treatment, and that depends on what movements aleve the pain and what movements increase the pain. So that combination of those two things can help reduce symptoms a lot.

Chris: For a period of time I figured that ibuprofen and acetaminophen were essentially were interchangeable, but they’re not.

Dr. Walker: No.

Chris: You put them in different categories now.

Dr. Walker: Yes. You can use them concurrently together, barring any side effects. Ibuprofen, Aleve help to reduce the inflammatory aspect of pain. Whereas the Tylenol, also known as acetaminophen, can help the nociceptive or the, the actual sharp aspect of pain that a person may have.

Chris: So far, most of the things we’ve talked about, I could handle myself in my own medicine cabinet without seeing a physiatrist. So let’s talk a little bit about what you as physiatrist can do, like maybe for the next level up. Are there maybe injections you can use or certain types of — we already talked about physical therapy a little bit, but — other maybe approaches to how we conduct our day-to-day that might not involve something over-the-counter that I might have in my pantry?

Dr. Sakalkale: Well, as Dr. Walker correctly said, the initial treatment is always with the over-the-counter or prescription strength anti-inflammatory medications. In addition to that, we also prescribe muscle relaxants to go with that, to help with the pain. If these measures do not help, then we do a more investigative workup to find out what the actual source of the pain is.

The investigative method can be imaging studies such as MRI, which kind of pinpoints the source of their pain. And when we make up our mind about the source of the pain, then the treatment approach in terms of the type of injection depends on what the findings are. The injection can be anything from a trigger point injection into the muscles or ligaments versus doing a spine injection or an epidural or facet joint injection under fluoroscopy guidance.

In both these instances, what we inject is a medicinal steroid, which reduces the inflammation. The effect of the medication takes few days to work, and typically by a week or two down the road, we know whether it made any difference or not.

Chris: Sometimes we hear talk of cortisone shots, but you can only get so many of those, right, in, in a certain amount of time? When someone gets that, what’s happening there?

Dr. Walker: So cortisone is, it’s kind of a colloquial term, thats term. Steroidal injections use a couple of different types that are indicated to be placed into the epidural space or inside the joint. Generally, like Dr. Sakalkale was mentioning, is pinpointing the target of where the pain generator is located is key. That may take a couple of injections to figure out that. Once that’s determined, then the physiatrist that’s helping to manage that interventional care can help the patient decide how frequent they may need it. That frequency, it really depends on what the patient’s goals are functionally, as well as goals treatment wise they may have in the long run.

So, for instance, if that patient is an athlete per se, they may get an injection a couple times throughout a year. If the patient’s goal is more functional and they’re a home exerciser per se, that frequency may change as well. So it’s tough to say that, “Hey, you’re going to have one every two months, one every four months, one every six months.” it’s really an individualized treatment.

Chris: And one thing that’s important to understand is you generally don’t prescribe narcotics or opioids as a part of what you do here.

Dr. Walker: What’s interesting, yes, so what’s interesting is, there are evidence-based guidelines that are used for spinal care. Generally, for that 80% of patients that have back pain once in their life, that 10%, 20% may have back pain continually, studies have shown that long-term opiate use doesn’t improve their function, and sometimes it doesn’t overall reduce their pain. So yes, a lot of times we’re not going to use an opiate medication to treat their chronic lower back pain or subacute lower back pain.

Chris: And somebody might come in to see you and think, “Alright, they’re going to give me some kind of narcotic. My pain’s going to go away by tomorrow.” But that’s probably part of the discussion you need to have too, when a patient comes in, right?

Dr. Sakalkale: That is correct, because it’s a common expectation on the part of the patient that they have sort of a microwave mentality. They want everything fixed within a day or within an hour, to be frank. But that never happens in reality. So we have to have some realistic discussions with the patients, which we usually have from the get-go. And we tell them that these treatment options are going to help him or her, but in a gradual manner. And at some point in time, they will see improvement not only in their pain level, but also in their function, because functional improvement is the most important thing that keeps them going.

Chris: And before we say goodbye, I want to talk just a little bit about the risk-benefit analysis that takes place in many, many aspects of medicine — no different I’m sure for pain management, when you have different types of options for approaching it, right?

Dr. Walker: Yeah, so once again, it’s an individualized process. We’ll start with interventions. With interventions, you’re going to want to know, what is the medical status of that patient? Do they have diabetes? Do they happen to have heart disease? Are they on blood thinning medications? That kind of adjusts what type of interventional treatment that person may have. Regarding medication risks and benefits, once again, knowing the patient’s medication status, knowing the patient’s health status, interesting enough, knowing the patient’s environmental status is also important.

Some main risks with using, let’s say, opioid medications can be addiction risk. The physician’s going to want to talk with them about potential addictive properties that the medication may have if it’s used from time to time. Additional aspect is an increase of tolerance of taking those medications. There has been studies that show that the longer a person takes opioid medications, the more that they may need to get that same amount of pain relief. There’s also an overdose risk that the patient may have. It’s important that if they’re on those opioid medications, that they have access to medications like Narcan, as such, to help reduce any unintended consequences. There are side effects of those medications that have to be gone over with the patient as a potential risk. If they’re on other medications, that’s also wanted to be talked to them about as well.

Chris: Very good. Gentlemen, I appreciate your time today. That is Dr. Joseph Walker and Dr. Durgadas Sakalkale, both UConn Health physiatrists. Thank you so much for joining us today.

Dr. Sakalkale: Thank you.

Dr. Walker: Great, thank you.

Chris: That is our time for today. For Dr. Walker and Dr. Sakalkale, I’m Chris DeFrancesco. Thank you for listening to the UConn Health Pulse. Be sure to subscribe so you can catch us next time, and please share with a friend.