“In almost all cases, there are one or more treatments that can significantly reduce that pain,” says the Scottsdale, Arizona-based doctor and board-certified pain specialist. “That’s why we use a comprehensive integrated approach, where patients have access to treatments from physicians, chiropractors, physical therapists and naturopaths. It’s a patient-centered approach that puts safety first.”

Realistically, some chronic pain may not be completely eliminated. Dr. Lynch reminds patients of that and works with them to set realistic goals for pain reduction.

“We pride ourselves on managing pain safely, and the first step isn’t getting out a prescription pad. We listen, assess a person’s pain well and start with the least invasive treatments.”

Dr. Lynch has developed a few tools to help. One is an easy-to-follow protocol to help determine if a patient needs something as strong (and potentially risky) as opioids and if that patient is a good candidate. If opioid therapy is used, the second helpful tool is a 12-Step Opioid Checklist to ensure that both patient and physician are on the same page about safety.

GPS, A HOLISTIC APPROACH

“We look at pain differently. The way pain is traditionally measured in clinical settings—often with just a couple of questions where pain is rated from 0to 10—misses much of the impact of chronic pain on other aspects of a patient’s life: emotions, work, activities of daily living,” says Dr. Lynch.

To fully understand a patient’s pain,he and his medical partners developed the Global Pain Scale (GPS), a 20-item questionnaire that can be completed in just two minutes.

The GPS includes traditional questions about pain intensity, but also assesses how pain is affecting emotions, sleep, work, hobbies and social activities. Dr. Lynch has made the GPS available to other medical practices on his website.

In 2007, Dr. Lynch developed a 12-step compliance checklist for patients and physicians to review together before considering long-term opioid therapy.

THE OPIOID THERAPY CHECKLIST

“We developed the opioid therapy check list to clearly establish the conditions for the responsible use of opioids for chronic pain,” Dr. Lynch says. “It’s becoming the standard of care for responsible pain medicine at other practices, as well.”

Most pain doctors today acknowledge that opioids have been overprescribed. That trend began before the medical community realized the extent to which people could become addicted and how long-term use could create a different set of problems.

But opioids still have their place in pain management. “There is good evidence that opioids can treat acute pain, such as pain occurring soon after an injury or surgery, as well as chronic cancer pain,” Lynch says. “Studies have found that opioids reduce pain by an average of 28 percent. However, they have the downside of increasing morbidity and mortality.”

THE OPIOID CHALLENGE

High doses—or the equivalent of 100milligrams or more a day of morphine—are potentially dangerous, Dr. Lynch says. “We feel opioids are not justified for most chronic pain patients. Not only are there diminishing returns on pain relief above this point, but, for some patients, high doses of opioids can even lead to a condition called opioid-induced hyperalgesia in which the high doses of opioids actually increase their pain.”

The way different doses of opioids work is often counterintuitive. “Intuitively, one might think if a certain dose of opioids provides 30percent pain relief, then doubling that dose would provide 60percent pain relief,” Dr. Lynch explains. “Not only is that assumption usually wrong, the doubled dose may even provide less pain relief than the previous dose but with more side effects and the risk of addiction or overdose.”

lynch1

MORE DOWNSIDES AND DANGERS

Opioids have a laundry list of unpleasant side effects that range from mildly irritating to life-threatening. Constipation is among the milder but most common potential drawbacks.

“In men, opioids can decrease testosterone and sex drive,” Dr. Lynch says. “Opioids can also increase a patient’s risk of accidental injury.”

And of course, there’s well-documented risk of opioid abuse and misuse. “This is greater for those with previous problems with addiction, but there’s no single profile of people who become dependent,” says Dr. Lynch. “It can affect young and old patients, men and women and people of all economic backgrounds.”

Opioids can cause respiratory depression that can be fatal. These kinds of serious reactions are more likely inpatients on high doses of opioids and/or in combination with other drugs, such as alcohol, anxiety medications and sleep medications.

Opioids cause more than16,000 deaths each year in the United States, says Dr. Lynch—compelling evidence that the utmost care must be used when prescribing them.

OPIOIDS, A LOOK BACK

Why do opioids continue to be a go-to choice for some doctors even though their dangers are well documented? It’s useful to know the history.

Beginning in the 1990s, there was an increased recognition that opioids could be used for chronic pain conditions beyond cancer pain, Dr. Lynch explains. Doctors wanted to help their patients dealing with severe pain. Opioids worked.

“This use helped alleviate suffering in many cases, but many doctors didn’t sufficiently weigh the risks,” he says. “There was a dramatic rise in the number of opioid-related deaths from the 1990s to today. There’s now an increasing awareness among doctors that opioid medications require clear policies and restrictions as well as careful management to be used safely.”

lynch4OPIOIDS’ PLACE IN PAIN MANAGEMENT

There are certainly patients who can benefit from opioid therapy, Dr. Lynch says, but even most of those patients should be on low to moderate doses.

“Opioids are never the first option,” he says. His practice uses more conservative treatments such as chiropractic care, physical therapy and bracing and behavioral health therapy such as biofeedback. Muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), membrane stabilizers, epidural steroid injections, nerve blocks and spinal cord stimulation are all part of his repertoire.

“A comprehensive, integrated approach is important because individual patients vary in their response to treatments,” says Dr. Lynch. “In many cases, combining treatment modalities leads to better relief than a single treatment.”

The 12-step opioid checklist Dr. Lynch developed is a useful starting point for physicians and patients weighing the risks and benefits of opioids. “The treating physician should assess the patient, including assessment of pain, a physical examination and appropriate diagnostic tests, such as X-ray, MRI or EMG,” he says. “A clear rationale for opioid use, such as degenerative disc disease of the lumbar spine, should be documented.”

Lynch’s advice for doctors? “Have a serious conversation with the patient about opioids before beginning treatment. This includes discussing any history of substance abuse and any issues—such as depression—that may require a referral for additional treatment.”

Patients need to be informed about the risks of opioids. Doctor and patient should establish realistic goals for opioid therapy and review those goals together regularly to ensure opioids are providing continued benefit and not causing harm.

Dr. Lynch believes it’s imperative that only one physician prescribe all opioid medications for a single patient.

“Patients who receive opioids from more than one doctor are at greater risk of overdose because each doctor may not have a complete picture of the patient’s medication regimen,” he says. All other medications a patient is taking should be regularly reviewed, too, as there is potential for dangerous interactions.

For the patient’s health and safety, doctors have to be diligent about ensuring compliance. Dr. Lynch uses a routine urine drug screening to monitor his patients on opioids. He even takes the additional step of reviewing the state pharmacy board reports to ensure the patient is not filling other prescriptions that haven’t been reported to the doctor.

“When steps including these are followed, it’s possible for opioids to be part of a relatively safe and effective treatment plan for chronic pain,” he says.

But opioids are not the only route to reducing chronic pain. And they should never be the first choice. {PP}