During a surgery at GBMC, Alan Lake received a nerve block to diminish the need for narcotic pain medications. This is a new treatment doctors are using to find alternative treatments for pain. (Kenneth K. Lam/Baltimore Sun video)
After doctors at the Greater Baltimore Medical Center removed part of Dr. Alan Lake's small and large intestines earlier this month, the retired pediatrician felt so little pain he didn't need the powerful opioids most patients receive after major surgery.
Instead, doctors administered other, less addictive pain medication before and during the surgery as part of new "enhanced recovery" protocols being used by the hospital in colorectal surgeries to reduce recovery time and complications. Lake was given three non-addictive painkillers before his surgery to reduce pain and sensation in the intestine. Doctors also placed a nerve block in the surgery area during the procedure to more directly target the pain.
GBMC also no longer requires patients to fast or remain on bed rest for several days after these surgeries, and it also stopped giving them large amounts of IV fluids. The medical community now believes these once common surgical protocols cause more harm than once suspected.
The change in procedures is occurring as doctors face pressure to prescribe fewer opioids and other narcotics that can lead to addiction in some patients. Opioid addiction is fueling what's become a nationwide heroin epidemic as addicts turn to the cheaper, more readily available street drug.
The Department of Health and Mental Hygiene announced earlier this month that it was instituting new rules for prescribing opioids to Medicaid patients that would force doctors to consider alternative painkillers, start with low doses and better screen patients for risk of abusing prescription drugs. The new rules also encourage doctors to refer more addicted patients to treatment.
The American College of Physicians this week announced new guidelines for treating lower back pain — one of the most common reasons for doctor visits — with therapies such as massage, spinal manipulation or acupuncture rather than drugs. If drugs are needed they should be anti-inflammatory drugs or muscle relaxants, the group said.
"Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies, as they are associated with substantial harms, including the risk of addiction or accidental overdose," said Dr. Nitin S. Damle, the group's president, in a statement announcing the guidelines.
As doctors adopt the guidelines and hospitals establish new practices, many in the medical community hope alternative pain treatments like the protocol being used at GBMC become the norm.
"When you start talking about the problem with narcotics, it is huge," said Dr. John J. Kuchar Jr., chairman of GBMC's department of anesthesiology. "Although it can be good for short-term use, it is certainly not the panacea we all would have hoped it would be. You don't want people walking around with a bag full of pills and getting addicted to them."
Dr. Lake couldn't agree more. The 70-year-old retiree from Glen Arm was back home within three days of his surgery and walking around his yard, to the surprise of his neighbors. He performed many surgeries during his career as a pediatric gastroenterologist and never expected recovery could be so easy. He said his pain threshold on a scale of 1 to 10 was a 2 after the surgery. The only painkiller he needed was Tylenol.
"Having the ability to use less narcotics and recover faster is all good as far as I'm concerned," he said.
Enhanced recovery is one of the newest ways doctors are treating pain. Researchers are also looking at how regenerative medicine can treat pain. For instance, scientists are isolating platelets from blood and injecting them into joints. Platelets contain growth factors that promote healing, said Dr. Edward Soriano, who heads The Center for Pain Treatment and Regenerative Medicine at LifeBridge Health. Other researchers are injecting stem cells into various parts of the body in an effort to promote healing.
"There are so many non-narcotic treatments that can be used as a first response," Soriano said. "Once people get on narcotics, getting them off becomes a much bigger challenge and issue."
Other pain management alternatives have been used for years, such as nerve blocks, and prescription-strength Tylenol and ibuprofen. Doctors also say that patients should stick with physical therapy or try less traditional treatments, such as yoga, meditation and even acupuncture.
But doctors say it can be difficult to get patients to adhere to alternative treatments that may require repeated visits to a practitioner's office. These therapies can also be physically uncomfortable and tedious; taking a pill is easier. Some insurance companies also don't cover some alternative treatments such as acupuncture or treatments that are still in medical trials and have not yet been approved by the federal government.
"We are a society of instant gratification," said Dr. Bahador Momeni, regional director of the University of Maryland Community Medical Group. "Take a tablet and feel better. Insurance won't cover something like aqua therapy, but they cover prescriptions. As a society, we need to change our approach if we want to solve this problem."
Momeni and other doctors said opioids have a place in pain management, mostly for short-term recoveries, especially after a major surgery or medical procedure. But they say it is better to try other treatments for chronic conditions.
For example, Momeni recommends his patients get water therapy — exercising or doing physical therapy in a pool — to treat pain. He believes many of these problems are linked to weight and other lifestyle issues and water therapy can help people lose weight and also be therapeutic to muscles. Restorative exercises are also easier to practice in the water.
Howard General Hospital endeavors to offer patients a wide range of pain treatment options and will combine some treatments, said Dr.Steven Levin, the hospital's medical director for patient medicine.
Howard also uses pre-emptive pain treatment methodslike those of Greater Baltimore Medical Center. One of the hospital's more unusual treatment options is electrical stimulation to suppress pain signals.
"Pain specialists have long had the feeling that comprehensive care is the best care," Levin said. "The more you can offer the patient to treat their pain, the less likely the patient will become addicted to opioids."
Dr. Steven P. Cohen, chief of pain medicine and director of clinical operations at Johns Hopkins Medicine, is studying whether alternative pain treatments can reduce opioid use in patients already using the drug. So far he has found that it does not. The results will be published the journal Anesthesia & Analgesia.
"Opioids work very well when you first take them, but then they lose their effectiveness," said Cohen, who is also director of pain research at Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences. "You don't really see a lot of evidence that support ongoing effectiveness for more than three months."
Daisy Harris, 79, of Laurel was using low doses of the opioids oxycotin and fentanyl to treat pain after a knee and hip replacement and back pain. She decided to stop using them a couple of years ago because what she heard about people getting addicted started to spook her. She threw out a bottle of 60 oxycontin pills and began looking for alternatives.
As the former head of a health clinic, Harris saw firsthand how addiction gripped some of the patients. "I just don't want to become overly dependent on them," she said. "I don't want to over take them."
Harris worked with Dr. Levin at Howard General to come up with an alternative pain management plan. She now uses occasional steroid injections, physical therapy and anti-inflammatory drugs to treat her pain,
Harris hasn't ruled out using opioids again if her pain is excessive, but she hasn't needed to since she started using alternative treatments.
"I have no problem with opioids," she said, "but let's try to manage the pain first."