Numbing the Body Electric

Why is opioid addiction such a big deal in 2016? It’s not exactly news that prolonged usage of these drugs can lead to a high tolerance for pain medication, addiction, and/or overdose; one needs to look no further than heroin to understand that. Some legally prescribed opioids are much stronger than that—Fentanyl, the drug allegedly responsible for late music icon Prince’s death, is approximately 80 times more potent than morphine. By comparison, heroin is about two or three times stronger.

One peek at National Institutes of Health (NIH) statistics on overdose deaths from prescription opioid pain relievers illuminates the sudden—though long overdue—interest in this problem. According to NIH, from 2001 to 2014 there was a 3.4-fold increase in the total number of national overdose deaths. Perhaps most unsettling to see was the disparity between 2013 and 2014, rising from under 16,000 in the United States to around 20,000. To contrast, the number of 2014 overdose deaths from heroin—which in the public mind is considered to be a much larger issue­—totaled about 11,000.

What is contributing to this growing epidemic? Most of the blame is placed on the pain management strategies of healthcare professionals—most doctors aren’t equipped with the knowledge to treat severe chronic pain with anything but opioids. Lawrence Poree, M.D., M.P.H., Ph.D., medical director at the Pain Clinic of Monterey Bay, professor at the University of California-San Francisco’s School of Medicine, and a panelist in a discussion on America’s opioid dilemma and the possible medtech solutions that took place at this year’s Advanced Medical Technology Association (AdvaMed) annual meeting, claims aspiring doctors are not learning enough about alternative treatments. “Fundamental education of medical students needs to occur,” he entreated.

According to Konstantin Slavin, M.D., professor and head of section of stereotactic and functional neurosurgery at the University of Illinois-Chicago (and a panelist alongside Poree), having worked outside the United States, the opioid epidemic is almost exclusively an American problem. The ripple of anxiety passing through the audience was nearly palpable as he dropped the knowledge that 99 percent of opioids are sold in the U.S. He also informed the crowd that in other countries, opioids are not prescribed at the outset, but rather viewed as a last resort to effectively manage pain. Physicians outside the U.S. are not penalized for not prescribing opioids—something that is certainly a foreign concept to practicing U.S. doctors. Instead, according to Slavin, they ask other, more practical questions first, such as “Will corrective surgery resolve the pain?” or “If the patient is using a neurostimulating device to manage the pain, are the device’s algorithms correct?”

This illustrates arguably the most promising method to control pain without opioids: spinal cord stimulation (SCS) technology. In short, SCS delivers mild electrical stimulation to nerves along the spinal column via an implant, modifying or blocking nerve activity to minimize the sensation of pain reaching the brain. Readers savvy in this technology may remember that St. Jude Medical Inc.’s latest iteration of SCS technology, BurstDR Stimulation, received U.S. Food and Drug Administration approval in early October.

“As a physician, reducing the physical sensation of pain experienced by my patients is only part of my job; my ultimate goal is to help patients overcome both the physical pain and the suffering associated with their pain,” Dr. Timothy R. Deer, president and CEO of The Center for Pain Relief in Charleston, W. Va. (and final panelist of the AdvaMed discussion), said in a press release. “[this] new therapy option…can reduce patients’ pain and suffering, reduce paresthesia, and help us offer our patients a more complete pain management option.”

To tout the benefits of SCS as a viable pain management option, Deer told the story of a soldier who had gravely injured himself in a skydiving accident. The patient’s resulting injuries put him in enough pain to confine him to a wheelchair, and Deer was flabbergasted at how many opioids he had been initially prescribed by his referring doctor; they were enough to render the patient practically sedentary. Thankfully, he was referred to Deer—and due to the implantation of SCS technology, the soldier has been living mostly pain-free for about seven years. He is even able to walk again despite his horrific injuries.

All the panelists agreed that SCS technology has made great strides in the past few years, but it is still not nearly as widely adopted as it should be. “Technologies are usually offered years after the initial diagnosis,” Poree said.

According to Deer, “controlling pain down to level 6” in order to “improve function, satisfaction, comorbidity, and mortality” must be a higher priority than simply prescribing opioids for pain. He said that in order for SCS technology’s scalable adoption by physicians, public awareness must also be drastically raised. Patients simply don’t know that options like SCS are available because physicians either don’t view them as practical, or otherwise aren’t aware of the technology’s benefits. Which, by the way, includes cost—according to Slavin, payers are inadequately educated about the cost of SCS technology. “Neuromodulation is cost effective,” he said, “but payers don’t want to become aware.”

As with any surgery, SCS implantation has its risks. But all  panelists agreed that those risks paled in comparison to the risks of long-term opioid use—which the NIH overdose data certainly backs up. Further, though the initial cost of SCS implantation surgery may be high, costs arising from the potential comorbidities of opioid abuse—which may not be limited to money—would likely be much higher.