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America’s opioid epidemic is known throughout the world as a major public health crisis. Yet debates about what needs to be done persist while people die due to opioid overdoses. 

And doctors are still tasked with treating patients suffering from chronic pain, despite the increased pressure to reduce opioid prescriptions. 

Perhaps, as physicians, the first step to doing our part in addressing the problem is to treat chronic pain the way it should be. Yes, we all want to help alleviate our patients’ pain. However, the word pain should not produce a knee-jerk reaction of prescribing pain medication.

What is the appropriate treatment for chronic pain?

• First line treatment: Opioids should never be used as first-line treatment for chronic pain. According to physical medicine and rehabilitation (PM&R) specialist Mahmud Ibrahim, MD: “First-line therapy for most musculoskeletal issues is physical therapy, NSAID’s, chiropractic care, and acupuncture”. 

• Fixing function: Most painful medical conditions occur because something is not functioning the way it should be. It is not OK just to prescribe pain medications without diagnosing the true problem and trying to correct it.

• Physical therapy (PT): I find that many patients have many misperceptions about this treatment modality. The goal of PT is not to eliminate pain but rather to restore function. When the dysfunction is eliminated, the pain will go away. Patients often don’t give it enough time. 

• Procedures: Certain procedures often can replace the need for pain medications. According to Dr. Ibrahim, “With regards to the spine, I can perform injections from the base of the skull to the coccyx.I can do epidural steroid injections, facet injections, radiofrequency ablations, spinal cord stimulator trials and implants, and disc procedures. With regards to the peripheral joints, I can inject pretty much every joint/tendon/bursa”.

• Alternative therapies: In my practice, many patients come to me already on opioids prescribed by another provider without having tried any other therapeutic options. In the surgical specialties, surgery is often reserved as the option of last resort. The same should be true for the treatment of chronic pain. Before we prescribe these powerful pain killers, we should prescribe the above-mentioned options first. While there may not be a plethora of evidence for the effectiveness of acupuncture, for instance, it is a pretty safe procedure to try. 

• Addressing patient expectations: Doctor often fail to address or even discuss patient expectations. For many conditions, there may be nothing that can be done to completely take pain away. If patients are aware of what is expected, they can make better-informed decisions. If they know some pain is normal, maybe they won’t be asking for that opioid.

• Specialists: Many patients who come to me as new patients using opioid medications prescribed by another provider either received them in the ED or from another primary care doctor. However, I think we do the patient a great injustice when we fail to refer them to the appropriate specialist. Just treating their pain is never going to fix the underlying dysfunction, which only gets worse over time without appropriate care. We should be referring chronic pain patients to the specialists with the highest degree of training to treat them: PM&R physicians.

• Education: As doctors, we need to do a better job giving patients all the options. How else can they make an informed decision? “I think that lack of patient education is a big problem,” says Dr. Ibrahim. “Many patients don’t know that there are other options other than opioids for their pain.”

The debate around opioids will likely continue for years to come. Yet, doctors have the opportunity to do something about it today. Instead of reaching for that prescription pad or the e-prescribing tab, pause and ask yourself what functionally can be done to help eliminate the patient’s pain. If you don’t know the answer to that question, consider referring the patient to someone who can.

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