5 Trends in Pain Management for Today’s Wound Care Clinicians

Pain can be extraordinarily complex to control and is often inadequately managed, leaving more than 100 million adults in the United States living with chronic pain.¹ Early, appropriate interventions of acute pain, however, can prevent chronic pain, a serious disease that involves changes to the nervous system that can lead to greater perception of pain severity. Acute pain also hampers function and can cause delayed wound healing. Fortunately, there are more treatment options available for pain today. Some therapies, however, face reimbursement challenges. Not all treatments are approved by the U.S. Food & Drug Administration and, sometimes, decision-makers may be slow to recognize the potential for treatments to alleviate pain and improve health, to cite examples. Moving forward, the following therapies may prove to have great utility and potential to treat patients living with pain related to chronic wounds. Of course, clinical efficacy and appropriateness, as well as reimbursement, could impact the extent to which particular populations benefit.

HYPERBARIC OXYGEN THERAPY 

This now decades-old technology increases the penetration of oxygen to tissues to improve the quality and speed of wound healing while exposing individuals to 100% oxygen at a pressure that is higher than atmospheric pressure. All tissue requires oxygen to heal properly, and exposure to 100% oxygen can help wounds heal more rapidly. From a pure pain perspective, many professional athletes have discovered the transformative healing properties of hyperbaric oxygen therapy (HBOT), which can help them to quickly recover from injury and return to the field of play more quickly than previously anticipated. HBOT is also used for certain types of wounds, such as infections, burns, grafts, diabetic ulcers, and radiation injuries. Side effects are rare when the modality is utilized appropriately, but can include pressure-related trauma, nearsightedness, convulsions, and decompression sickness. There are ethical considerations that must be weighed regarding the use of HBOT that all wound care clinicians (and other healthcare providers) should be cognizant of, especially as it relates to off-label use.²

REGENERATIVE MEDICINE 

The rapidly emerging field of regenerative medicine offers considerable potential to produce a higher quality repair of injured tissues through accelerated healing and decreased scar formation. Biologic products containing stem cells or growth factors hold promise that they can repair nerve endings and tissues on a microscopic level while reducing pain to a tolerable level. Faster healing of wounds and reduced inflammation result in diminished pain and restoration of function. Regenerative medicine options include adipose- and bone marrow-derived autologous stem cells, human amniotic membrane and umbilical cord-derived tissues, platelet-rich plasma, umbilical cord blood, and amniotic fluid products. While data on clinical efficacy and safety of some of these products are lacking, amniotic membrane tissues have a well-documented track record of clinical success, having long been used to heal ocular injuries and, more recently, for the treatment of difficult-to-heal chronic wounds. 

OPIOIDS & OTHER MEDICATIONS

There has been a bit of a perfect storm, in which an opioid epidemic and subsequent trend of healthcare providers becoming overly cautious related to when to prescribe certain medications, that has resulted in some patients being prevented from receiving appropriate pain management and creating an environment in which some practice guidelines appear to be based on emotions and stereotypes as opposed to science.³ Opioids, an effective category of pain medication for the last 5,000 years, are still greatly misunderstood by both patients and physicians. A lack of knowledge about the many different opioid molecules and technologies that are available has resulted in the overprescribing of opioids, incorrect prescribing of opioids, and undertreatment of pain — with patient harm and death as a consequence in some cases. Oxycodone is not the only opioid, yet it is synonymous with opioids. Some opioids cause a lower dopaminergic response than others, creating less “likeability” and euphoria. When these opioids are combined in formulations that have extended-release and abuse-deterrent properties, patients receive sustained pain relief without the highs, feel “less drugged,” and are less likely to abuse the medication. New abuse-deterrent technologies make it very difficult (or impossible) to extract or alter the opioid molecule, preventing the drug from being snorted or injected. There are also novel opioid molecules in the research pipeline that are purported to have an extremely low addiction profile. A carefully chosen opioid molecule and technology can be used safely, effectively, and appropriately among patients living with chronic pain, especially as that pain relates to chronic wounds. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in relieving pain, but they also vary greatly in their efficacy and side-effect profile. Some have an exponentially higher risk of renal damage and gastrointestinal bleeding. Low-dose technologies exist and safer NSAID molecules are readily available. For patients living with neuropathic pain, most opioids are not effective. NSAIDS may help, but not enough to the point that they provide adequate relief. Medications specifically for nerve pain should be considered. The most common category is the gabapentinoid molecules. One important strategy in managing pain with medications is to take advantage of different mechanisms of action by prescribing low-dose combination therapy that delivers effective pain relief while minimizing side effects. While medication management may not be a new treatment, prescribing responsibly seems to be a new concept in pain management.  Thus, this category is just as important as it has been for years.

MEDICAL CANNABIS

Currently, medical cannabis is legal in 29 states and in Washington, DC, and the list is slowly growing. Anecdotally, patients who use medical cannabis have had significantly improved function and reduction in chronic pain from diseases such as osteoarthritis, rheumatoid arthritis, fibromyalgia, and cancer. In a 2015 survey of patients who used medical cannabis (77% for fibromyalgia, 63% for arthritis, and 51% for neuropathic pain), people reported experiencing “a lot or almost complete overall pain relief.”⁴ Research on medical cannabis has been severely hampered in the U.S. due to cannabis listed as a Schedule 1 substance. Research has been conducted in other countries with promising data. In the experiences of this author, patients who have used medical cannabis have reported improvement in sleep and reduction in chronic and nerve pain without the deleterious side effects associated with marijuana. Some medical cannabis products have low delta tetrahydrocannabinol — the psychoactive molecule in cannabis — which can act synergistically with cannabidiol — the component of cannabis that has anti-inflammatory and analgesic properties — to relieve pain. Patients who use cannabis can develop a psychological or habitual dependence to the drug that is different than the addiction seen with nicotine and opioids. Side effects of medical cannabis include sedation and altered mental function, and, in adolescents, cannabis can interfere with normal neural development. State law determines which medical conditions qualify for medical cannabis use. In Illinois, for example, open wounds and chronic pain are not qualifying conditions. Internal wounds, such as Crohn’s disease and spinal cord injury, are covered and eligible for a medical cannabis card. Although some pain experts argue that medical cannabis should be a first-line treatment for pain, patients must first apply for that medical marijuana card, which can take months to acquire (by which time they may try other interventions). 

LONG-DURATION ANESTHETICS & NOVEL ANESTHETIC PREPARATIONS

Slow-release anesthetics given perioperatively to patients undergoing surgery and living with preexisting wounds, or those who will develop postoperative wounds, may decrease the intensity of postoperative acute pain, thereby cutting the use of opioids and reducing the risk of patients subsequently developing chronic pain. When an injury or a wound occurs, both organic damage to the peripheral tissue and inorganic changes to the central nervous system take place.

Due to the limited duration of action with spinal blockade, epidural blockade, nerve blockade, and infiltration of regular local anesthetics, anesthetics that have a longer half-life or technologies that allow for a longer duration of action have been developed. Encapsulating technologies have emerged as a leading option. Encapsulation of the local anesthetic enables prolonged release and extended duration of action. Additionally, encapsulated analgesics present with a lower side-effect profile due to the lower peak plasma concentration, lower systemic exposure, and lower risk of overdose. Liposomal bupivacaine is an encapsulated slow-release anesthetic that is injected into the surgical site. The nano-sized particles release their contents as they dissolve, resulting in prolonged analgesia for 72 hours. Liposomal local anesthetics have a short shelf life and may be expensive. As a result, researchers continue to focus on the development of additional products and technologies, such as implantable anesthetics, polymer-based formulations and polymicrospheres, injectable pastes and solid polymers, and proliposomal products. 

Jay Joshi is a double-board-certified and fellowship-trained anesthesiology and interventional spine and pain-management physician. He is chief executive officer and medical director of the National Pain Centers in the Chicago area. He discloses no financial conflicts of interest.

References 

1. Relieving pain in america: a blueprint for transforming prevention, care, education, and research. The National Academies of Sciences, Engineering, and Medicine. 2011. Accessed online: www.nationalacademies.org/hmd/reports/2011/relieving-pain-in-america-a-blueprint-for-transforming-prevention-care-education-research.aspx

2. Fife CE. Ethical considerations for approved & off-label use of hyperbaric medicine. TWC. 2018;12(3):11-4.

3. Joshi J. Wound treatment that’s more than skin deep: focusing on pain management. TWC. 2017;11(12):15-8.

4. Troutt WD, DiDonato MD. Medical cannabis in arizona: patient characteristics, perceptions, and impressions of medical cannabis legalization. J Psychoactive Drugs. 2015;47(4):259–66.