Physicians have long been interested in approaches to chronic pain management that are less prone to abuse than traditionally prescribed medications. But the ongoing opioid crisis in America has shone a light on how a combination of increased heroin use, dubious prescription and pharmaceutical practices, and the increased amount of fentanyl drug dealers have added to heroin have combined to kill tens of thousands of additional people on a yearly basis. There’s a real problem growing in America, and new treatments for chronic pain could potentially address it, via drug delivery implant systems and intrathecal electrical stimulation.
Before we dive into the science of these new systems, it’s important to get a sense for the scale of the crisis. The graph above runs only through 2015, but early data suggests that 2016 fatalities rose 19 percent over the 52,404 recorded deaths in 2015. The death rate throughout 2017 already suggests this year will be even worse.
The medical establishment’s flawed response
Faced with a growing problem, states and the medical establishment have responded in a variety of ways. Some states have tightened the rules around opioid prescriptions, as have many doctor groups and industry organizations.
On the one hand, this increased policing of patient drug use makes sense. Spiking mortality rates in heroin and fentanyl since 2010 have driven much of the recent increase, but opiate mortality rates have been rising in line with prescription rates since 2000. Some have argued that our increased reliance on opiates for chronic pain management can be ultimately traced to a five-sentence letter published in the New England Journal of Medicine in 1980.
But on the other hand, treating all patients like drug-seeking addicts is precisely the wrong response. There are tens of millions of Americans who are older or on disability. Retired blue-collar workers who worked on factory lines or in physically demanding jobs for decades face real challenges in chronic pain management.
New York recently passed a law called ISTOP, ostensibly aimed at curbing the opioid abuse epidemic by cutting off the supply of opioids given to doctor-shoppers. It made all prescriptions electronic, and added an extra step for health care practitioners to look up patients in the “did this patient ever use a narcotic or other scheduled drug” database. So while the addictive potential of opiates is fueling this crisis, there’s a critical need for pain maintenance systems that don’t require doctors and patients to view each other through a web of suspicion and distrust.
NYS instituted a law that not only curbs abuse (which is excellent), but also inconveniences literally anyone who seeks pain medication — and anyone else unlucky enough to be caught up in the dragnet.
We’ve previously discussed one potential method for dealing with chronic pain management that would obviate this problem. Last year, the FDA approved an implant that administers a controlled dose of the painkiller buprenorphine at a constant, steady rate. These implants are similar to the birth control implants like Nexplanon, which women have used for years. The implants can maintain a steady blood serum concentration that even carefully regulated oral dosing from conscientious patients struggles to match.
Because the level of pain killers in the blood remains steady, patients don’t experience a waxing or waning effect from their medication. And implanting the drug in the body in a long-term distribution system removes any possibility of abuse.
There are existing methods for delivering medication to the spinal column via an intrathecal pump, but such pumps are expensive and require surgery to implant. A Nexplanon-like implant, in contrast, could be injected at a doctor’s office through a needle; no surgery at all. And then all of a sudden you don’t have to go to bed wondering if you’ll wake up in pain so intense you won’t be able to sit up and reach your pain meds.
The other potential option for chronic pain management that wouldn’t rely on opiates or drugs is a spinal cord stimulator. These devices share some commonalities with the brain control implants we’ve discussed in other stories, and they function as described: by sending a mild electrical pulse into the spinal column. The electrical pulses “modify and mask the pain signal from reaching your brain.”
SCS doesn’t work for all patients, and it doesn’t generally completely eliminate pain, with a 50-70 percent reduction considered a strong result. It’s not a perfect solution (like an intrathecal pump, an SCS requires surgery), and the ability of the device to reduce pain varies significantly depending on the cause of the condition.
Still, between implant systems, SCS, intrathecal pumps, and even BCIs, we’re seeing some positive movement on this front. Given the rapid increase in opiate dependency, and an aging population of Boomers with chronic pain challenges, treatments that don’t rely on opiates or create conflict between doctors and patients can’t arrive quickly enough.
Top image credit: Probuphine implant, Braeburn Pharmaceuticals