Opting out of opioidsAnd why acupuncture may be an alternative treatment option August 24, 2016 By Narda Robinson, DVM, DOAll too often we hear about celebrities such as Prince falling victim to opioid overdose.1 The story goes that Prince suffered from chronic pain and took the fentanyl on which he overdosed to “try to control the constant, excruciating pain from damaged hips.”2 Could this have been prevented? Were opioids the only option? Had other methods of treatment been tried? While Prince’s death was notable and tragic, the numbers of deaths in his and other age groups is astounding and climbing.3 In fact, at some medical examiners’ facilities, space for those who have died due to opioid overdose is running out.4 As such, the bodies are piling up. Veterinarians are at risk of substance abuse as much as others, if not more. And they have access to prescription opioids, meaning veterinary professionals should be seeking alternatives to treat the pain, stress and despair that can accrue over time. Physician’s Role The cost to society of prescription opioid abuse amounts to a substantial and escalating economic burden on society. Projections indicate the problem is only going to increase and the toll it exacts will become more painful.5 However, while tens of billions of dollars are being consumed by this self-perpetuating tragedy, the etiology of the illness goes largely unaddressed. That’s because the problem with prescription opioid abuse is not just the drug, it’s the prescription. Drugs don’t prescribe themselves. Physicians, in this author’s opinion, are driving this epidemic. It’s not that they do so with bad intent or are unaware of the risks. It’s that they are stuck in a mindset of “opioids first” and “opioids often.” The American College of Emergency Physicians provides an illuminating portrayal of the denial rampant within modern medicine. They write: “Many patients seeking care in the emergency department (ED) present with severe pain, which may be due to an acute or chronic condition. A primary goal of emergency care is to alleviate pain quickly, safely, effectively and compassionately. Opioid medications remain the mainstay for treatment of severe pain.”6 They continue: “Treatment of chronic pain with long-acting opioid medications is a primary driver of the opioid epidemic, made worse by the aging population. Misuse and diversion of these medications is a serious problem, but significant numbers of these agents are rarely prescribed from the ED.” I disagree. The web page adds, “It is important for emergency physicians to understand that while they are not the primary cause of the opioid abuse epidemic, they do have a role to play in fighting it. Because of the patient population they treat, emergency physicians are frequent prescribers of opioids [italics mine] and thus may become targets for overzealous regulators.” Does this not contradict the previous paragraph? Introduce Acupuncture Considering that nearly half of emergency department visits have a pain component,7 pain clearly needs to be addressed. But that response to patients’ pain does not need to reflexively resort to opioids. While opioids may be necessary and even desirable for the short-term treatment of acute, severe pain, they have become the default analgesic for all types of pain patients within the emergency department.8 This is contributing substantially to the public health crisis of opioid addiction. We have alternatives to opioids, such as acupuncture. Randomized, controlled trials demonstrate the effectiveness of acupuncture for various pain problems, including neck pain, back pain, osteoarthritis and headache. In fact, a variety of nonpharmacologic therapies are receiving mention in emergency medicine journals. To quote a recent paper, “[T]rue multimodal analgesia, the use of around-the-clock non-opioids with opioids as rescue agents, is now a standard in acute pain guidelines. Further developments in assessment and treatments tailored to the type of pain and the individual patient’s risk factors will lead to more effective pain management, and may improve emergency physicians’ ability to provide rapid, effective pain relief while minimizing risks of abuse and adverse effects.”9 Acupuncture should be considered within that multimodal analgesic treatment plan. It has been reported effective for musculoskeletal pain, low back pain, appendicitis pain, renal colic and sickle cell vaso-occlusive events.10 It may be tailored to the patient’s specific type of pain, can be implemented in both acute and chronic care settings, and eliminates the worry of increased risk of drug dependence and abuse. Acupuncture Advantages In summary, here are 10 reasons that doctors, nurse practitioners and others that prescribe opioids for pain should instead be counseling patients on approaches, such as acupuncture, that will allow them to control their pain without relying on narcotic pharmaceuticals. Acupuncture works for several types of acute and chronic pain. 11-14 Acupuncture works in the perioperative and postoperative setting. 15,16 Acupuncture does not lead to tolerance and addiction. Acupuncture addresses the source of the problem, such as myofascial dysfunction, inflammation and nerve entrapment; opioids do not. Acupuncture does not worsen chronic pain, but opioids can.17 Acupuncture does not cause respiratory depression. Opioids do. Acupuncture can address pain while patients try to get off of opioids. Acupuncture treats constipation. Opioids cause it. Acupuncture treats nausea.18 Opioids cause it. Acupuncture, combined with drugs such as benzodiazepines, does not heighten the risk of death. Opioids do. Recent research reveals that patients in emergency settings who received acupuncture provided in conjunction with standard medical care found the treatment “acceptable and effective” for both pain and anxiety.19 The authors of this study wrote: “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 ED 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.” References LaMotte S. Celebrities who died from painkillers and heroin. CNN. June 3, 2016. Accessed on 07-01-16 at http://www.cnn.com/2016/06/03/health/gallery/celebrities-who-died-from-opiods/ Berry L. Prince did not die from pain pills – he died from chronic pain. RawStory. May 6, 2016. Accessed on 07-01-16 at http://www.rawstory.com/2016/05/prince-did-not-die-from-pain-pills-he-died-from-chronic-pain/ Gourlay K. In Prince’s age group, risk of opioid overdose climbs. NPR. May 5, 2016. Accessed on 06-27-16 at http://www.npr.org/sections/health-shots/2016/05/05/476902228/risk-of-opioid-overdose-climbs-at-middle-age Cohen J. Details on death certificates offer layers of clues to opioid epidemic. NPR. June 1, 2016. Accessed on 06-27-16 at http://www.npr.org/sections/health-shots/2016/06/01/479440834/in-opioid-crisis-it-s-important-to-know-which-drugs-caused-a-death Birnbaum HG, White AG, Schiller M, et al. Societal costs of prescription opioid abuse,dependence, and misuse in the United States. Pain Medicine. 2011; 12:657-667. http://www.asam.org/docs/advocacy/societal-costs-of-prescription-opioid-abuse-dependence-and-misuse-in-the-united-states.pdf American College of Emergency Physicians website. Opioid resources. Accessed on 07-01-16 at https://www.acep.org/opioids/ Pollack CV and Viscusi ER. Improving acute pain management in emergency medicine. Hosp Pract. 2015;43(1):36-45. Personal observations made in hospitals regarding the treatment of patients of a variety of ages, states of health, and comorbidities. Recently, for example, I accompanied my father to the hospital for a wound infection on is foot. The nurse inquired about his level of pain, and he said he had none when recumbent, but a 4 or 5 when standing and applying pressure. Fifteen minutes later, the nurse reappeared with two tablets – one was a narcotic and the other an antiemetic medication to treat the nausea the opioid might cause. My father refused the drugs, and in so doing evoked a bewildered expression from the healthcare provider. Apparently, having a patient not accepting opioid medication happened rarely. Another patient underwent rather complex abdominal surgery and had moderate pain after surgery. For postoperative pain, she received a prescription for Percocet. She took one but disliked the dizziness and lightheadedness it caused. She asked her doctor for something else, and she received Vicodin. This caused similarly unpleasant sensations, so she went with an over-the-counter non-steroidal anti-inflammatory medication which resolved the pain and kept her mind clear. Yet another patient had spinal surgery and went home with a bottle of oxycodone that he never used. They sit on the shelf with other untouched narcotics prescribed from various emergency room visits and orthopedic procedures. It’s not that this individual has an unusually high tolerance for pain – he found other methods that worked better for him without causing the undesirable side effects of opioids. These are not unusual cases – just representative examples. Pollack CV and Viscusi ER. Improving acute pain management in emergency medicine. Hosp Pract. 2015;43(1):36-45. Cited in: Tsai S-L, Fox LM, Murakami M, et al. Auricular acupuncture in emergency department treatment of acute pain. Ann Emerg Med. 2016; http://dx.doi.org/10.1016/j.annemergmed.2016.05.006 Trinh K, Graham N, Irnich D, et al. Acupuncture for neck disorders. Cochrane Database Syst Rev. 2016; May 4;(5):CD004870. doi: 10.1002/14651858.CD004870.pub4. Lin R, Zhu N, Liu J, et al. Acupuncture-movement therapy for acute lumbar sprain: a randomized controlled clinical trial. J Tradit Chin Med. 2016 Feb;36(1):19-25. Moss DA and Crawford P. Ear acupuncture for acute sore throat: a randomized controlled trial. J Am Board Fam Med. 2015;28(6):697-705. Graff DM and McDonald MJ. Auricular acupuncture for the treatment of pediatric migraines in the emergency department. Pediatr Emerg Care. 2016. May 2. [Epub ahead of print]. Asmussen S, Maybauer DM, Chen JD, et al. Effects of acupuncture in anesthesia for craniotomy: a meta-analysis. J Neurosurg Anesthesiol. 2016 [Mar 10]. Epub ahead of print. http://www.ncbi.nlm.nih.gov/pubmed/26967459 Wu MS, Chen KH, Chen IF, et al. The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis. PLoS One. 2016 Mar 9;11(3):e0150367. doi: 10.1371/journal.pone.0150367. eCollection 2016. Brush DE. Complications of long-term opioid therapy for management of chronic pain: the paradox of opioid-induced hyperalgesia. J Med Toxicol. 2012 Dec;8(4):387-92. doi: 10.1007/s13181-012-0260-0. Zhang AL, Parker SJ, Smit deV, et al. Acupuncture and standard emergency department care for pain and/or nausea and its impact on emergency care delivery: a feasibility study. Acupunct Med. 2014 Jun;32(3):250-6. doi: 10.1136/acupmed-2013-010501. Epub 2014 Mar 7. 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] Originally published in the August 2016 issue of Veterinary Practice News. Did you enjoy this article? Then subscribe today!