Dr. Shuchita Garg talks about safe alternatives to opioids

Chronic pain is an issue that millions of people deal with on a daily basis. With the over-prescription of opioids, the world has fallen into a crisis – with over 40,000 people dying of opioid-related causes every year.

It was in the late 1990s when various pharmaceutical companies reassured the medical fraternity that they should not be worried about patients getting addicted to opioids when used for pain relief.  After that, there was an increased prescription of opioids, which resulted in the abuse of both the prescribed and non-prescription opioids. It was later when the results of studies were analyzed, the reality of its high risk of addiction set in. Hence, it was not until 2017, that Health and Human Services (HHS) declared that the opioid crisis was now a public health emergency.

Dr. Shuchita Garg is a physician committed to finding opioid-free alternatives for chronic pain. She is currently an active member of the Care Innovation and Community Improvement Program, A Quality Improvement Strategy program. It is an initiative of Metrohealth System, Ohio State University Wexner Medical Center, UC Health and the University of Toledo Medical Center. They are working to create a quality strategy to improve health outcomes across various specialties. One of the many domains focuses on improving health outcomes in patient populations at-risk-of or with an opioid or other substance use disorder, which is her area of expertise.

She is a member of multiple organizations, including the American Society of Pain, Ohio Society of Interventional Pain Physician, and American Society of Anesthesiology, and is currently on the national task force for the formulation of working guidelines for lumbar facet mediated pain blocks and interventional procedures.

Her current research centres around the efficacy of steroids in providing back pain relief, and in identifying the biomarkers responsible for Complex Regional Pain Syndrome (CRPS) in order to improve treatment outcomes.

But before we delve into opioid alternatives, let’s explore what the problem with opioids is in the first place.

The issue with opioids:

Opioids provide effective pain relief, right? So, what’s wrong with them?

I believe that the current healthcare system produces fragmented care with poor delivery of necessary medical interventions when needed in the setting of chronic pain patients. This results in the rampant abuse of opioid or “narcotic” pain medications, unnecessary treatment with expensive injections and procedural interventions including surgery and a wide variation in the quality of pain care delivered across the country.

Having said that, while opioids are generally very good at relieving acute pain following trauma or an operation, they aren’t so good in the long-run. Studies have found that not only are they less effective at treating pain over a long period of time, but that the long-term use of them also comes with significant side effects and can create dependence – they can even contribute to the development of illicit drug addictions.

The reason why they started being used to treat chronic pain was because of a strong marketing campaign back in the 1990s. As such, opioids were prescribed routinely in high-income countries like the United Kingdom, Australia, and the United States. As a result, thousands of people are dying every year from overdoses to this drug – in higher rates than motor-related incidents. This is why you have likely heard it being referred to as the “opioid crisis”.

What can be done

The solution to the opioid crisis is complex, as it requires a number of action steps to be taken by different groups. For instance, governments should fund campaigns highlighting the dangers of long-term opioid use, whereas GPs should avoid prescribing them for chronic pain. The treatment of chronic pain should be comprehensive and involve a number of health practitioners in order to get the best outcomes for patients.

Alternative pain relief solutions

While new treatments for chronic pain are still in the works, there are a number of existing treatments that may prove helpful to some people. Of course, the right treatment will depend on each individual case and condition. Some of the treatments used are:

Physical therapy 

Physical therapists use exercise, massage, and manipulation of the body in order to relieve pain and inflammation and promote rehabilitation. Physical therapy works by promoting the body’s natural ability to ease pain and heal itself. A physician can help by creating a personalised exercise program and/or treatment regime, which might include swimming or deep-tissue massage.

Injections

For those with nerve pain or muscle spasms, a local anaesthetic injection can assist with pain relief.

Psychological therapy

Psychological therapy, such as CBT, can be beneficial in that often anxiety and depression accompany chronic pain, and learning to deal with these issues can help to ease your experience of pain somewhat. For example, learning to reframe negative thinking can help you better cope with pain and can boost your mood.

Surgery 

If other treatments don’t work, surgery may be needed to fix any abnormalities in the body, which might be the source of the pain.

Do patient expectations about pain and opioids change things? I believe you have a publication about this.

There is scarce data and an understanding of the beliefs related to the majority of chronic pain conditions. Much research is ongoing to investigate various tools to establish a relationship. And yes, I do have a publication that deals with patient beliefs and expectations in pain and disability. Certain beliefs do indeed impact pain acuity and modification and are known to affect outcome and recovery. Accessible evidence suggests that patient beliefs, attitudes, and expectations can affect the outcome and response to treatment. Maladaptive behaviours appear to be significant fillers in patients when there is an absence of concordance between pre-existing pathology and clinical presentation. The National Advisory Committee on Health and Disability has identified ‘maladaptive attitudes and beliefs about back pain’ as a significant risk factor for the development of long-term disability from back pain. It is a challenging task for physicians to manage chronic pain when patients have associated maladaptive cognitions regardless of a precise diagnosis and analogous treatment.

Would you be able to tell us more about the Care Innovation and Community Improvement Program, that you are a part of?

Well it’s an honor to part of this team. We are working on multiple things, but I will like to be as concise as possible. The “smart aim” is to decrease the rate of opioid use over the next three years by 12.01%. This is a strong step to combat the current opioid epidemic that our country is facing. The Task Force aims to identify the drivers for high opiate prescriptions among the prescribers and aims to implement interventions to address these drivers. Some of the identified drivers are:

1. Provider, patient and community knowledge and awareness of the problem
2. Excessive prescribing of opiates during routine care
3. Challenges in managing patients who are already opiate dependent, tolerant or addicted and limited non-opiate treatments for pain, especially for patients with chronic pain
4. Limited access to addiction treatment
5. Limited use of technology to understand current prescribing practices and to promote best prescribing practices

Formation of a stewardship committee that is comprised of physicians from different specialties will help to form consensus guidelines on both in and out patient opiate prescription guidelines. The goal is to adhere to the most recent CDC guidelines on the safe prescribing of opiate medications.

Summary

There are many existing alternatives to opioids for chronic pain and many which are currently being explored. Dr. Shuchita Garg’s passion for improving her clients’ quality of life and care shows in her extensive body of work – with four chapters and multiple published peer-reviewed medical journal articles, she is an excellent physician to visit for managing chronic pain.