When you’re in pain, you just want it to stop as quickly as possible. We’ve all been there at some point. For me, it was a car crash that left me with severe pain in my lower back and shoulder. My father – a physician himself – recommended I see an osteopathic physical therapist, who performed manual therapy and gave me a stretching and exercise program to follow at home.
Two weeks later, I was completely “cured.” The pain was gone and I was dumbfounded. That’s what prompted me to earn a Doctor of Osteopathic Medicine degree and that’s what prompted me to apply for a select fellowship in interventional pain management at the Medical College of Virginia (now VCU Medical Center).
I’m grateful to my father for pushing me toward the physical therapist. All too often, people in pain get narcotics in a fast but inefficient attempt to ease their suffering. I understand the urge, but narcotics don’t work very well in the long run.
The problem with narcotics
The first thing to understand about narcotics is that there are different types used for treating different problems. Some types of narcotics work on the nerves and some work on the joints. In general, primary care physicians aren’t experts in pain so they may not be aware of which drugs to prescribe; or they may not be sure whether your exact problem is caused by a neuropathic issue or a joint issue.
As often as not, people with legitimate pain didn’t get their pills from a doctor anyway – they got them from a friend who had a few left over after their own injury. So the pills may not actually work on your pain; you just may not know that because narcotics – even the wrong ones – will make you feel better right away. That’s not pain relief though; it’s euphoria. It still hurts, you just don’t care. Essentially, you’re too high to mind the pain, which means that not only are you not functioning well, you’re not getting better.
Over time, that just gets worse; your pain increases because you aren’t dealing with it and your psychological need for the narcotic also increases. So you hurt all the time and you crave relief all the time but the relief gets shorter and shorter and the pain gets more and more intense.
There are a lot of alternatives to narcotics and for most patients, we try them all before we turn to narcotics. We use both holistic and traditional medicine, depending on the patient and the problem.
An integrative approach to medicine includes massage therapy, chiropractic, manipulation, plant-based supplements and CBD oil.
CBD oil is a fairly new treatment and the one that still raises eyebrows. CBD (which is technically called cannabidiol) is now legal in Virginia and in many other states and is a way of treating pain without producing euphoria. THC is the most active ingredient in marijuana and the one that produces euphoria. Because CBD products don’t have THC, they can make your body feel better without making you high. CBD and marijuana are both cannabinoids and the human body produces its own cannabinoids as well. The TCH in marijuana attaches to the body’s brain receptors that deal with coordination, pain, emotions, mood, thinking, and appetite; that is, they alter your mind and give you the munchies. CBD, however, doesn’t seem to attach to receptors at all. Instead, it seems to prompt the body to use more of its own cannabinoids, particularly the ones in the immune system that affect inflammation and pain.
So CBD, along with other nonnarcotic medications and injections, is exactly the kind of thing we’re looking for in treatment; we want your body to feel better without your brain realizing it because when your brain realizes it, it’s generally because you’re not really better – you’re just high.
If we’ve tried everything else and nothing works, we do look at narcotic treatment but out of 7,000 patients at Integrative Pain Specialists, fewer than 50 are on narcotics.
If we do prescribe narcotics, it’s usually only after conducting a comprehensive narcotics assessment with a psychologist to ensure that they are safe for the patient. One tool is the ORT or opioid risk tool, which estimates a person’s risk for misusing narcotics. The ORT is a series of questions about the patient’s gender, age, personal and family history and mental health. Based on the responses, it calculates a percentage chance of narcotic abuse.
That’s not a perfect test, of course. Just because a person is statistically likely or unlikely to abuse narcotics doesn’t mean they should – or should not – get them. We also have another tool at our disposal – a new DNA test that analyzes pain. In essence, it’s a “lie detector” for pain.
Are patients lying about being in pain? Not exactly; chronic pain with narcotic addiction is a complicated psychological and physical issue. Just as the narcotics can make you not care that you’re still in pain, they can also convince your brain that you’re still in pain when you’re not – you’re just addicted to the narcotics. The DNA test can tell the difference.
We don’t give a narcotic assessment to everyone in our practice. Patients with serious cancer or those with major spinal injuries, for instance, forgo the narcotics assessments.
When we do prescribe narcotics, we always go for the long-lasting ones rather than the short-term drugs. Short-acting narcotics chase your pain and leave you as a prisoner to time. If your back hurts and you take a pill every four hours, you’re always watching the clock, counting down to the next pill. That’s especially true because the pills take a while to kick in and they always seem to wear off before the next dose. So you hurt before it’s time for the pill and you hurt after taking the pill and in between, maybe you feel better – or you feel euphoric — but you always know that you’ll be hurting again in a couple of hours. That’s no way to live.
Long-acting narcotics are only used every three to seven days. Butrans is a good one; it’s a narcotic skin patch that you put on and leave on for a week. It’s an extended release drug, so it doesn’t produce euphoria, and you just replace it with a new one every Sunday and don’t have to think about it.
But it’s still a narcotic and we don’t use it except as a last resort.
No one gets narcotics on their first visit to our office and when a patient walks in and says “the only thing that works on my pain is narcotics,” that’s a red flag.
The fact is that we don’t prescribe narcotics because we don’t need to. Other treatments work better. And our patients almost never ask for them – they get referred to our office because they want to actively treat their pain, not ignore it.
The bottom line is that patients who work towards pain management through physical therapy, manipulation, injections, and nutrition, are always more successful than those who just take narcotics. I’m grateful to have learned that after my own car crash and I’m glad to be in a position now to help others realize it as well.
Benjamin Seeman, DO is the head physician at Integrative Pain Specialists. Board-certified through the American Board of Physical Medicine & Rehabilitation with a fellowship in pain management, Benjamin specializes in osteopathic techniques and integrative therapies for managing pain. He has been voted Richmond Magazine’s Top Doc since 2012.