“Pain that continues when it should not.”
That’s how the American Chronic Pain Association defines chronic pain, from which roughly 50 million Americans suffer.
There are, of course, many well-known treatment methods for pain—non-narcotic drugs such as acetaminophen, aspirin and ibuprofen and narcotic medications like morphine and methadone, for example.
New techniques and technologies continue to emerge, however, that offer healthcare providers more options in their effort to help combat patients’ chronic pain. We asked experts to weigh in on what they see as pain management trends that will help shape pain management in 2021 and beyond.
An uptick in telehealth services
Of course, COVID-19 has disrupted the delivery of healthcare, which continues to affect those living with chronic pain, says Asmina Khan, MD, director of the interventional pain clinic in the department of anesthesiology at Santa Clara Valley Medical Center.
“Treating intractable pain patients is necessary, and can help keep them out of the emergency department, and thus free up hospital staff.”
The pandemic will continue to limit in-person care, and healthcare providers “will need to continue to communicate with telemedicine and video visits to reduce the gaps in communication,” says Khan, noting that insurance companies will need to expand reimbursement rules regarding payment for telehealth services.
(Indeed, research finds the use of telehealth services rising dramatically in the 10 months since the coronavirus pandemic arrived in the U.S.)
Looking ahead, Khan foresees more health educational tools being made available for patients virtually.
“The most important aspect of pain management is not score, but to improve the pain so the patient can improve his or her activities of daily living as well as his or her work and hobbies,” she says.
“Patients may not be able to attend physical therapy sessions to help manage pain and improve function, so providers will need to continue to encourage continued movement and offer adapted exercise options. More virtual physical therapy options might be available in 2021.”
Patients with intrathecal pumps will still need to keep up in-person visits on a regular basis, in order to refill pump medications, says Khan, adding that providers might reduce face-to-face time by conducting interviews over the phone and making in-person appointments only for the procedure portion of the pump refill.
“When the patients do come in for office visits, the contact precautions, social distancing and the use of personal protective equipment (PPE) will continue in the ongoing attempt to flatten the curve of the pandemic.”
Lowering steroid doses
There is little evidence to suggest harm in using corticosteroids to treat asymptomatic patients who may have COVID-19, or those who subsequently test positive for the coronavirus, says Khan.
“When corticosteroid administration is considered,” she says, “patients should be made aware of all potential risks from immunosuppression during the COVID-19 pandemic.”
Side effects to the immune and endocrine system appear to be dose-dependent, so lower doses could potentially mitigate possible negative side effects.
As such, “providers may continue to use lower steroid doses in 2021,” says Khan.
Dealing with degenerative disks
Degenerative disks are one contributing factor to chronic low back pain (CLBP), says Michael Danto, MD, a board-certified specialist in physical medicine and rehabilitation at the Orthopaedic Specialty Institute and the Hoag Orthopedic Institute.
“There are particular degenerative changes seen on MRI, called Modic changes, that are known to be a cause of CLBP, and the basivertebral nerve transmits the pain signals from these disks,” says Danto, noting a “brand-new technique” that uses radiofrequency energy to ablate the basivertebral nerve of the spine and block the pain coming from these degenerative disks.
“This has huge implications for the treatment of CLBP and is probably the biggest new technology in pain management,” he says.
With regard to chronic lower back pain, biologics, or regenerative medicine, such as platelet-rich plasma and bone marrow aspirate are also being used as treatment, adds Danto.
While stressing that these treatments are “truly experimental at this stage, [regenerative medicine has] shown promise. I think that, in the coming years, the use of biologics will steadily increase.”
RFA is trending upward
Radiofrequency ablation (RFA) has been used to manage arthritic pain in the spine for decades, says Danto.
“The procedure, which is very safe and minimally invasive, has been refined over the years, and is now extremely effective in managing pain from arthritic joints in the spine,” says Danto, who has been performing radiofrequency ablation more than 15 years.
“So, it’s not cutting edge by any means,” he says. “[But] with our aging population and the decline of surgical intervention for CLBP, the popularity of this procedure increases each year. I see this procedure continuing to trend upward in pain management.”
Blocking pain from the peripheral nerves
As Dawood Sayed, MD, division chief of pain medicine at the University of Kansas Health System, told Elite Healthcare in 2020, “minimally invasive pain treatments like spinal cord stimulation are moving more frontline.”
“These treatments are given early on, when patients experience pain instead of using surgery and medications upfront,” said Sayed. “These are moving up the treatment algorithm as a frontline therapy.”
Danto predicts a continuing rise in the use of peripheral nerve stimulation, which, similar to spinal cord stimulation, can be performed to block chronic pain coming from the peripheral nerves and joints, says Danto, noting there is new technology in peripheral nerve stimulators that doesn’t require implantation of a battery unit.
“This allows targeting of peripheral nerves more easily to block pain from these peripheral nerves or from joints, such as the knee, shoulder and sacroiliac joints.”
Increased interest in alternative therapies
Recent studies show medical educators and researchers “increasingly exploring nonpharmacological treatments for pain,” according to the Association of American Medical Colleges.
With the increased acceptance of “non-conventional medical methods” such as herbal supplements, yoga and meditation, for example, unconventional treatments for chronic pain have grown significantly in the past two decades, according to Verywell Health, on online resource for health information on a variety of medical topics.
These various treatments are collectively referred to as complementary and alternative medicine (CAM), notes Verywell Health, which lists massage therapy, acupuncture, hypnosis, magnetic therapy, tai chi and herbal or dietary supplements among the most common CAM treatment types.
“Some of the treatments now used in conventional medicine, such as chiropractic care and herbal supplements, existed outside of mainstream medicine for a long time,” Verywell Health reports. “More importantly, many people suffering from chronic pain have found some degree of relief.”
Tetrahydrocannabinol (THC) is another non-traditional treatment method that has grown as a pain management tool, sometimes prescribed to help alleviate back, muscle and joint pain.
And, while not a new technique, the use of medical marijuana “remains in the spotlight, as bills to legalize its use come before state legislature off and on,” notes Verywell Health.
And, while its use remains controversial, “a growing body of clinical research and a history of anecdotal evidence support the use of cannabis for the relief of some types of chronic pain,” notes U.S. Pharmacist, “including neuropathic pain and spasticity associated with multiple sclerosis.”
Getting away from opioids
Multimodal medication management “has long been the standard of care in pain management,” says Danto, “but there has been a recent trend away from opioids.” (see sidebar)
Danto sees that trend continuing, “because we are learning more and more about the negative effects of long-term opioid use—opioid-induced hypersensitivity, overdose, addiction, chronic depression and mood swings,” for instance.
“There is a new class of drug, nerve growth factor inhibitor, which are non-opioid drugs that decrease pain due to osteoarthritis and CLBP,” continues Danto. “One of these drugs has already completed phase 8 trials and the FDA is currently reviewing the safety and efficacy data to determine if it will be released.”
The continuing popularity of topicals
Studies have shown the benefits of topical analgesics as a safe and effective tool for managing pain associated with arthritis, neuropathy or radiculopathy, myofascial or musculoskeletal pain, and tendonitis, for example.
Such medications “have already become very popular,” says Danto, who anticipates their popularity to continue to grow “because of their safety and availability.
“This includes cannabidiol (CBD), in many states, and lidocaine products, which are available over the counter,” he continues. “The more we use topicals, the more we learn about their safety. I think there will be more widespread use of topicals to help reduce the use of oral medications.”
- The American Chronic Pain Association, 2018. Accessed Jan. 6, 2020.
- Centers for Disease Control and Prevention, 2016. Accessed Jan. 6, 2020.
- American Journal of Managed Care. 2020. Accessed Jan. 8, 2020.
- Population Reference Bureau, 2019. Accessed Jan. 7, 2020.
- Elite Healthcare, 2020. Accessed Jan. 7, 2020.
- Association of American Medical Colleges, 2019. Accessed Jan. 7, 2020.
- Verywell Health, 2020. Accessed Jan. 8, 2020.
- U.S. Pharmacist, 2020. Accessed Jan. 8, 2020.
- American Journal of Managed Care, 2018. Accessed Jan. 8, 2020.