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More ways to minimize opioid reliance

And how veterinarians can help manage pain without using opioids

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Last month’s column explored the epidemic of addiction to prescription opioids in people and how veterinary medical professionals may be at more risk of becoming addicted than the general population, considering the access we have to controlled substances and the stress of day-to-day work.

It also looked at acupuncture as an evidence-based and rational alternative to the reflexive reach for opioids for acute and chronic pain. In military settings, for example, an approach called “battlefield acupuncture” is gaining wider acceptance as a tool to treat pain during active duty in a way that does not negatively impact a service member’s ability to perform. 1, 2 

Recent research reveals that emergency department patients who received acupuncture alongside standard medical care regarded the treatment as “acceptable and effective” for both pain and anxiety.3 

According to the study’s authors: “Given the rapid increase in opioid prescriptions for pain and the corresponding increased risk of opioid abuse—as well as the risk of adverse effects—it seems evident that the existing treatments for acute pain do not address the problem fully. Low-risk, effective approaches to relieve acute pain in the E.D. are needed to assist U.S. health systems with mitigating this epidemic. Acupuncture has the potential to be a tool for hospitals to address pain in addition to the medication-based care already being delivered.”

Other Options

In fact, a variety of nonpharmacologic therapies not only alleviates symptoms of pain and dysfunction but also may modify the disease in a beneficial manner, promoting healing instead of dependency.

In addition to acupuncture, a treatment that heals while it helps treat pain is photomedicine, i.e., laser therapy and treatments with light-emitting diodes, or LEDs. It effectively lessens neck pain, knee pain, myofascial discomfort and pain from tendinopathy.4-7 

Even when alternatives exist and show effectiveness, clinicians who don’t prescribe them or who recommend them too late risk robbing patients of clinically meaningful opportunities for drug-free pain control early in the disease process.

Fortunately, a stellar example of how to institute changes took place at St. Joseph’s Regional Medical Center in Paterson, N.J., where the head of the emergency department decided to shift the consciousness and attitudes of his physicians and nurses. He realized, “Our job here together is to look at the whole equation and understand how we can stop people from going from a prescription to an addiction.”8 

The staff eventually came on board. Now, “The E.R. staff is beginning to embrace the non-opioid options. ‘I’m thrilled,’ said Allison Walker, a nurse. ‘I’d hate to be the first to give Percocet to a teenager who dislocated his knee at hockey practice. And then he comes back a year later, addicted to opioids? I don’t want that on my conscience.’”

What has St. Joseph’s introduced as alternatives to opioids? Trigger point injection, acupuncture analgesia, nonnarcotic infusions, ultrasound-guided nerve blocks, nitrous oxide and music therapy, among other approaches.9 

This put them on the leading edge, according to a professor of emergency medicine at New York University

School of Medicine, but necessitated “a commitment to changing their entire culture.”

As stated by a New York Times columnist, “In doing so, St. Joe’s is taking on a challenge that is even more daunting than teaching new protocols to 79 doctors and 150 nurses. It must shake loose a longstanding conviction that opioids are the fastest, most surefire response to pain, an attitude held tightly not only by emergency department personnel, but by patients, too.”

Government Involvement

Increasingly, lawmakers and federal agencies are brainstorming to address the opioid epidemic. One lawmaker, U.S. Sen. Bob Menendez, recounted, “In 2012, there were enough opioid prescriptions issued—nearly 260 million—to give every man, woman and child in the country their own bottle of pills.”10 

Furthermore, the U.S. Centers for Disease Control and Prevention issued a special report, “CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016.”11 Its authors noted, “Of primary importance, nonopioid therapy is preferred for treatment of chronic pain.”

In terms of determining when to initiate or continue opioids for chronic pain, the authors indicated: “Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.”

Our Profession

How can veterinarians become forward-thinking, conscious participants in handling pain more proactively and integratively? First, they should learn the science behind physical medicine modalities such as acupuncture, massage and photomedicine. Then, study the evidence.

For example, a recent study from the Canadian Veterinary Journal demonstrated that by combining acupuncture and manual therapy in the treatment of canine musculoskeletal pain, veterinarians were able to provide immediate short-term improvement in dogs’ comfort and mobility.12 Improvements included owner-observed changes in play behavior, walking, trotting, jumping, going down stairs, rising from a recumbent position and reduced stiffness after rest or exercise. Owners had been blinded to the treatment schedule.

Other recent research involves the use of acupuncture for dogs suffering from neck pain13 and horses with myofascial pain.14 Photomedicine reduced requirements for postoperative analgesia in cats undergoing ovariohysterectomy15 and time to ambulation in dogs after hemilaminectomy.16 

Clearly, the amount of clinical research of nonpharmacologic opioid alternatives in veterinary medicine needs time to catch up to that available for humans. Nevertheless, the principles and practice of medical acupuncture and photomedicine translate well across species because both approaches are based on contemporary knowledge of anatomy, physiology and the body’s endogenous reparative processes.

References

  1. Spotswood S. Auricular acupuncture:  convenient technique for battlefield pain.  US Medicine.  June 2014. Accessed at http://www.usmedicine.com/agencies/department-of-defense-dod/auricular-acupuncture-convenient-technique-for-battlefield-pain/ on 08-03-16.
  2. Tsai SL, Fox LM, Murakami M, et al.  Auricular acupuncture in emergency department of acute pain.  Ann Emerg Med. 2016; Jun 7. pii: S0196-0644(16)30171-8. doi: 10.1016/j.annemergmed.2016.05.006. [Epub ahead of print]
  3. Reinstein AS, Erickson LO, Griffin KH, et al.  Acceptability, adaptation, and clinical outcomes of acupuncture provided in the emergency department:  a retrospective pilot study. Pain Med. 2016 Feb 25. pii: pnv114. [Epub ahead of print]
  4. Kingsley JD, Demchak T, and Mathis R.  Low-level laser therapy as a treatment for chronic pain. Front. Physiol. 5:306. doi: 10.3389/fphys. 2014.00306
  5. Mardh A and Lund.  High power laser for treatment of Achilles tendinosis – a single blind randomized placebo controlled clinical study.  J Lasers Med Sci.  2017;7(2):92-98.
  6. Youssef EF, Muaidi QI, and Shanb AA.  Effect of laser therapy on chronic osteoarthritis of the knee in older subjects.  J Lasers Med Sci.  2016; 7(2):112-119.
  7. Khalighi HR,  Mortazavi H, Mojahedi SM, et al.  Low level laser therapy versus pharmacotherapy in improving myofascial pain disorder syndrome.  J Lasers Med Sci.  2016;7(1):45-50.
  8. Duffy C.  New Jersey hospital emergency room becomes first in U.S. to end use of opioid painkillers.  PIX News.  March 28, 2016.  Accessed at http://pix11.com/2016/03/28/new-jersey-hospital-emergency-room-becomes-first-in-u-s-to-end-use-of-opioid-painkillers/ on 08-03-16.
  9. Hoffman J.  An E.R. kicks the habit of opioids for pain.  New York Times.  June 10, 2016.  Accessed at http://www.nytimes.com/2016/06/14/health/pain-treatment-er-alternative-opioids.html?_r=0 on 08-03-16.
  10. Duffy C.  New Jersey hospital emergency room becomes first in U.S. to end use of opioid painkillers.  PIX News.  March 28, 2016.  Accessed at http://pix11.com/2016/03/28/new-jersey-hospital-emergency-room-becomes-first-in-u-s-to-end-use-of-opioid-painkillers/ on 08-03-16.
  11. Dowell D, Haegerich TM, and Chou R.  CDC guideline for prescribing opioids for chronic pain – United States, 2016.  JAMA.  2016;315(15):1624-1645.
  12. Lane DM and Hill SA.  Effectiveness of combined acupuncture and manual therapy relative to no treatment for canine musculoskeletal pain.  Can Vet J.  2016;57(4):407-414.
  13. Liu CM, Chang FC, and Lin CT.  Retrospective study of the clinical effects of acupuncture on cervical neurological diseases in dogs.  J Vet Sci.  2015.  Dec 8.  [Epub ahead of print].
  14. Still J.  Acupuncture treatment of pain along the Gall Bladder meridian in 15 horses.  J Acupunct Meridian Stud. 2015;8(5):259-263.
  15. Marques VI, Cassu RN, Nascimento FF, et al.  Laser acupuncture for postoperative pain management in cats.  Evid Based Complement Alternat Med.  2015;2015:653270. doi: 10.1155/2015/653270. Epub 2015 Jun 11.
  16. Draper WE, Schubert TA, Clemmons RM, et al.  Low-level laser therapy reduces time to ambulation in dogs after hemilaminectomy:  a preliminary study.  J Small Anim Pract.  2012;53(8):465-469.

Narda Robinson, DVM, DO, MS, FAAMA, is president and CEO of CuraCore Integrative Medicine and Education Center in Fort Collins, Colo. Columnists’ opinions do not necessarily reflect those of Veterinary Practice News.

Originally published in the September 2016 issue of Veterinary Practice News. Did you enjoy this article? Then subscribe today! 

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