Although opioids are highly effective for chronic pain, they pose significant risks of misuse, addiction, and adverse effects. Nonopioid and nonpharmacologic therapies, which are at least as effective as opioids in managing pain for a variety of conditions,1 offer safer alternatives. In response to the opioid crisis, pharmacists are increasingly advocating for nonopioid strategies to optimize pain management and minimize risks. Sometimes, these can be as simple as managing mood disorders, improving sleep hygiene, or providing empathetic patient counseling.
Illustrative representation of the opioid epidemic / Antonio Rodriguez – stock.adobe.com
Melissa Durham, PharmD, MACM, brings a wealth of experience in managing chronic, non-oncologic pain. As an associate professor of clinical pharmacy and associate dean at the USC School of Pharmacy and Pharmaceutical Sciences, and a clinical pharmacist at the USC Pain Center, Durham has been at the forefront of patient care for over a decade.
By understanding the complexities of pain management and the potential benefits of nonopioid interventions, pharmacists can empower patients to make informed decisions about their treatment options. In her interview with Drug Topics, Durham shared insights on how to counsel patients who might be reluctant to discontinue opioid therapy, the value of multimodal therapy, innovations in the nonopioid landscape, and more.
Drug Topics: What are the most common nonopioid pain management strategies that pharmacists are currently implementing in their practice?
Melissa Durham, PharmD, MACM: Multimodal therapy is critical when it comes to pain management. We know this is the gold standard, using medications that work synergistically together. So, depending on the disease state and the disease process, you might choose a variety of different medications with different mechanisms, everything from antidepressants such as tricyclic antidepressants [TCAS] and serotonin and norepinephrine reuptake inhibitors [SNRIs] to anti-epileptic drugs like gabapentin or pregabalin, anti-inflammatory drugs, and even [adding] simple analgesics like acetaminophen [to] the mix is helpful.
Some of the more out-of-the-box things that we’ve been working with over the last several years are agents like ketamine, which is an n-methyl-d-aspartate [NMDA] receptor antagonist that we’ve been able to use pretty successfully to get opioid doses down as we taper people off. Other out-of-the-box therapies, like low dose naltrexone, are more expensive and cost prohibitive because they need to be compounded. But those are a few of the nonopioid things in our toolbox that we reach to, in addition to topicals, which can be helpful in taking the edge off, but those are some of the top ones that come to mind.
And then, of course, there’s non-pharmacologic therapies. It’s not just the multimodal therapy, but it’s also [taking a] multi-disciplinary approach, using physical therapy, occupational therapy, pain psychology, making sure patients’ mood disorders are under control as well as sleep is under control, [that’s] another important part of it too in managing pain.
Drug Topics: How can pharmacists effectively educate patients about nonopioid pain management options and what challenges do they face in communicating this information to patients who may be hesitant to try alternative therapies?
Durham: This is a big challenge, especially in my patient population. I have a lot of patients who are still on opioids [and] who have been on opioids for a very long time. It can be a bit of a hard sell to broach the subject about tapering when the medications that they’ve been on are viewed as enabling [them] to take part in their life the way that they want to, whether it be with work, social activities, intimate activities, things like that.
So, the way that I do it is that I say [to them], “Listen, you’ve been on this medication for a long time. It’s probably not necessarily working the way that we hoped it [would], you’ve probably built up a tolerance to it.”
Taking the angle around tolerance is a good way to start talking to them about how opioids can potentially predispose them to developing chronic pain, because—I don’t say this to the patient—they cause neural inflammation. They activate our toll-like receptors and our glial cells, and we know that that is bad for patients’ long term, especially if they have neuropathic type pain or mixed type pain.
I’ll tell them, “You know, opioids can actually maybe even worsen your chronic pain.” I often say, “You might feel better as we take you down,” because a lot of times they do, “[and] we’re going to add these other therapies so that way we can bring down your dose. Overall, it’s going to allow you to have less side effects from the opioids and you might feel a cloud lifting. You might feel more energy. You might feel better,” because I’ve seen that a lot. Bringing [up] experiences with real-life patients that we’ve had success with is another really good way to do it, too.
Saying that these other nonopioid therapies are tools that we can use to optimize their pain management [is helpful]. Just like I mentioned before, how using multimodal therapy is the gold standard, I counsel a lot on [how] combination therapy and working synergistically [together] really does help from all angles of their pain management.
Drug Topics: What role can pharmacists play in collaborating with other health care providers to develop comprehensive pain management plans that minimize the use of opioids?
Durham: We play a significant role in this. I do this every day that I see patients and throughout the week as well. We are the medication experts. We have a very different lens when approaching patient care than other folks who might be more focused in other areas.
I’m sort of a general practitioner pharmacist who specializes in pain management, which is kind of interesting. So, when my team sees a patient, we review the medications very thoroughly. Every single one of them. We’re not just focused on the ones that are for pain. We end up catching a lot of things that might have gone missed by other providers who have a narrower focus, or different focus, other than just medications. And then, as you said in the question, to develop a comprehensive plan that involves a multi-disciplinary approach, is something that can be really valuable for optimizing patient care outcomes.
Drug Topics: Are there any innovative nonopioid pain management strategies or technologies that pharmacists should be aware of?
Durham: Any time that we do anything innovative, there’s going to be barriers to access for a lot of patients. But putting that aside, some of the things that interventional pain management specialists do are pretty innovative things like injections. We have epidurals and joint injections and trigger point injections. I mean, that’s not that groundbreaking, those are things [that we’ve had] for a long time, but it might not be something that pharmacists think of.
A lot of things like implantable peripheral nerve stimulators and spinal cord stimulators—an interventional pain physician can get creative with things that may be outside the bounds of what we reach to normally. With pharmacotherapy, and then some of the therapies I mentioned previously, like using ketamine in unique ways, or low dose naltrexone, those are some things that not everyone is doing. Buprenorphine has been become much more popular. I don’t think everyone is necessarily doing it as much as they should but using that as another alternative for the traditional opioid therapies as well.
Those are some things that your run-of-the-mill pharmacist might not necessarily think of right off the bat, and I think other strategies or technologies that pharmacists should be aware of—I don’t even know how innovative this is, but I don’t know if everyone’s necessarily doing it—but trying to remove the stigma around patients with chronic pain. [It’s important] to remove the stigma around those who are taking opioid therapy, especially if they’ve been on [the medication] long term, and trying to really talk to patients and figure out what’s going on with them.
I think that if we’re looking, from even a community pharmacy perspective, a lot of doubts that we have or a lot of lack of information that we have can be solved by getting out and talking to people and figuring out what’s going on.
One of the big barriers that we have is lack of information. So, using that as a strategy—again, not super innovative, but that doesn’t mean people are doing it—can be very impactful and solve a lot of the problems that we think that we have.
READ MORE: Nonopioid Pain Management
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