Techniques Used to Lessen Opioid Use, Address Rheumatologic Pain

Nirav Shah, MD, is an attending anesthesiologist and interventional pain management specialist at Northshore University Health System and a clinician educator at the University of Chicago in Illinois.

During this interview, Dr Shah discusses neuromodulation and explains how it can potentially lessen pain caused by rheumatologic conditions as well as reduce opioid use.

Can you tell us a little bit about what neuromodulation is?

Neuromodulation is a blanket term that includes some techniques which rheumatologists who may be dealing with patients that suffer from chronic pain may be familiar with, and these techniques are subdivided into spinal cord stimulation and peripheral nerve stimulation.

Some of the latest and greatest techniques that we employ are dorsal root ganglion stimulation, which is a final evolution within spinal cord stimulation, where electrode leads are targeting the dorsal root ganglion at a specific nerve root or dermatomal level in the spinal cord area. That is one way to treat pain in a central way.

Then the alternative is peripheral nerve stimulation, which describes the neuromodulation of discrete peripheral nerves rather than any segment or connection of the spinal cord. It's less invasive. More recently developed forms of this do not require any permanent implants or any incisions whatsoever.

The idea is we use electricity that's delivered through various different waveforms to modulate the nervous system, and block pain signals from reaching consciousness, or even if they do reach consciousness, change how the patient's sense and suffer from them.

Why do you think this type of technology can benefit patients with rheumatologic disorders?

Patients with rheumatological conditions have multiple pain generators, due to both the underlying disease process and sometimes also as a side effect of the treatment to the disease.

Neuromodulation has its best evidence and efficacy when targeting sympathetically mediated pain and neuropathic pain syndromes, which are often present and comorbid in rheumatological patients.

We often find that chronic pain generators induce a neuroinflammatory state within the dorsal root ganglion where the neuronal cell bodies reside. By targeting these cell bodies with electrical energy, the pain signals that are being transmitted to the patient's central nervous system are thereby modulated, and the patient's pain and suffering are thus alleviated.

Can you give us an example of a patient with a rheumatologic disorder that received this treatment? What were the outcomes?

I sure can. There's been advancements in the field which have offered long-term results with, like I said, no permanent implants required. For example, I'm an early adopter of the SPRINT peripheral nerve stimulation system, which is FDA-approved for both acute and chronic pain.

It utilizes a percutaneously deployed neurostimulation lead which is placed near the target nerve for up to 60 days at which point it is simply removed by pulling out the lead.

From the rheumatological perspective, one of my recent patients was a middle-aged female smoker on high dose opioids suffering from rheumatoid arthritis, which had totally destroyed one of her knee joints. I saw her as a preoperative consult in my clinic ahead of total knee replacement surgery.

She was sent by her surgeon who was concerned by the amount of opioids she was taking, and whether he'd be able to control her pain postoperatively. I subsequently placed a two-lead peripheral nerve stimulation system targeting her femoral and sciatic nerves.

This was done within one hour in an outpatient basis. We were able to give her 100 percent pain relief in the days leading up to her surgery. This allowed her to taper down on her opioids which she was taking preoperatively.

She did very well postoperatively with the device in place with nearly no net increase in her opiate requirement, despite having major joint replacement surgery days before.

The beauty of this technology and approach is both as a bridge to surgery and as a way to treat either acute or chronic pain in the perioperative setting. There are no medications required. There are no side effects. We minimize the need for opioids up to 60 days post placement.

Alternatively, it is a good minimally invasive and reversible option for patients who are either not surgical candidates or do not want surgery.

What other options do you recommend for patients who are not good candidates for neuromodulation?

I'm glad you asked. I think that the very important thing is to develop early partnerships with interventional pain physicians in your area. It's very important to allow for optimal comprehensive treatment planning.

We are optimally suited to try non-opioid adjuvant pain medications, such as tricyclic antidepressants or serotonin and norepinephrine reuptake inhibitors, which are indicated for chronic musculoskeletal pain which many of these patients suffer from, as well as neuropathic pain and depression and anxiety, which is comorbid in many chronic pain patients.

We also can coordinate care with our colleagues and pain psychology field to develop chronic pain coping skills and deploy efficacious therapy strategies. By doing so, we also then utilize opioid-sparing interventional techniques.

Interventional techniques which can be utilized, can include, for example, ultrasound and x-ray guided injections, radiofrequency ablation, regenerative medicine, and even vertebral augmentation.

As you know, long duration exposure to corticosteroids can lead to osteoporosis, and I've often seen patients with vertebral compression fractures come into the clinic.

The key here is developing partnerships and involving interventional pain doctors very early on in the process to begin working towards controlling the underlying disease process on your end and treating the pain generators with the above modalities on our end, thereby we avoid starting the patient on opioids in the first place.

We can help them wean down when they're already on them when appropriate and able.

What are three takeaways about neuromodulation and other techniques for managing pain that you think rheumatologist should know about?

We should keep in mind three things. One, patient selection is key. Not every patient is a excellent candidate for neuromodulation or any implantable therapy, which you would see with spinal cord stimulation and dorsal root ganglion stimulation, but not necessarily with peripheral nerve stimulation.

The reason being, as you know, many of our patients that we treat together with rheumatological conditions have chronic immunosuppression -- they're on steroids -- which puts them at risk, especially if they also smoke or have diabetes for foreign body infection and wound healing issues.

We want to really make sure we select the right patients for these things. Number two, there's a variety of options out there for both central spinal cord stimulation as well as peripheral nerve stimulation targeting discrete nerve distributions.

It's good, like I said earlier, to partner with your interventional pain physicians to figure out what might be best as a trial for these patients, what might be a good long-term strategy for these patients, especially if there's any surgery in the upcoming time horizon.

Number three, opioids are generally not the answer. These are just some of the tools that interventional pain physicians can use to help treat these challenging patients and their pain generators in an opioid sparing manner.