By Jon Hagedorn, MD
The United States is currently battling an opioid epidemic that is only getting worse. The Centers for Disease Control and Prevention reported that in 2016 there were 42,249 opioid overdose deaths, which is a significant increase from the 33,091 deaths reported in 2015. Drug overdose is now the leading cause of death for Americans under the age of 50 (1). According to the Centers for Disease Control and Prevention, there were approximately 62 million patients that received a prescription for opioids in 2016 with 215 million total opioid prescriptions being filled (2). This massive amount of prescriptions has likely contributed to increasing heroin and recreational fentanyl use, as 75% of heroin users admit that their opioid addiction started with prescription opioids (3). Most opioid-related deaths are now from heroin and synthetic opiate medications (i.e. fentanyl and carfentanil). This has led the medical profession to seek alternatives to these complicated medications.
Opiate medications were not always perceived as dangerous. In 1980, Porter and Jick reported in the New England Journal of Medicine that only four of 11,882 hospitalized patients who received at least one narcotic medication while hospitalized developed opioid addiction (4). Six years later, Portenoy and Foley stated that only two of 38 patients who were receiving opioids for chronic nonmalignant pain showed signs of addiction (5). These two papers, cited over 2000 times in the literature, are often seen as the beginning of the opioid epidemic. They had created the idea in the medical community that opioid medications could be used safely for chronic nonmalignant pain. This, in addition to a growing concern nationwide that pain was being undertreated, led to pharmaceutical companies spending massive amounts of money to create longer acting pain medications. In 1995, OxyContin was released as a long-acting opioid for chronic nonmalignant pain. Purdue Pharma, creator of the medication, reported that the medication had very little addiction potential due to its long acting nature, and when seen in light of the above research, the medication was viewed as extremely safe. Physicians subsequently prescribed large numbers of this and other opioid medications. In 1996, OxyContin was prescribed 316,000 times. By 2002, that number had climbed to 7.2 million with sales tallying $1.5 billion (6). Prescription opioid numbers continued to increase for the next decade, leading the United States into the opioid epidemic we now face.
Due to our heavy reliance on medications to treat chronic pain in the past, the medical community has developed a multidisciplinary approach to chronic pain treatment. The strategy typically includes a wide variety of specialists, including chronic pain physicians, physical and occupational therapists, and psychologists. Together, these teams provide psychological care, activity and exercise, medication management, and interventional procedures aimed at lowering pain levels and improving quality of life. This approach has been very successful, and research has shown that certain modalities are effective at lowering opioid requirements in this patient population. Because of this, the field of interventional pain medicine, particularly neuromodulation, has seen tremendous growth in the past decade.
The term neuromodulation typically refers to spinal cord stimulation (SCS) when discussing chronic pain treatments. It consists of applying electrical current to the dorsal columns of the spinal cord in an attempt to block or decrease the pain signals to and from the brain. This is accomplished by placing stimulating electrodes in the epidural space, the implantable pulse generator (IPG) in the subcutaneous tissue of the lower back or abdomen, and wires to connect the IPG to the electrodes. A member of the team or implant company then programs the IPG to provide an individualized treatment plan for every patient. The patient has the ability to modify the IPG via a wireless remote. In traditional spinal cord stimulation, a paresthesia is mapped to cover the painful area. Newer, advanced technology allows chronic pain specialists to treat the painful area without creating paresthesias. This has led to increased patient satisfaction with SCS (7).
Spinal cord stimulation is indicated for failed back surgery syndrome (FBSS), complex regional pain syndrome, peripheral neuropathy, and limb ischemic pain when conservative measures and medications are not providing acceptable relief (8). While this technology is not appropriate for all chronic pain patients, the proven indications listed above are increasing in prevalence. As an example, FBSS is identified in 10-40% of patients that undergo spine surgery (9, 10). In 2011, approximately 600,000 patients underwent spine surgery in US hospitals. Even with conservative estimates of 10% incidence, this equates to 60,000 new patients with FBSS per year. If you consider that approximately 20% of spine surgery patients are opioid-dependent, the number of opioid-dependent patients that may benefit from SCS is at least 12,000 per year (11). While the other indications of SCS are less prevalent, the number of potential patients that could benefit from the opioid sparing effects of SCS is substantial.
The benefits of neuromodulation are numerous. First, SCS has been shown to improve patient pain scores and quality of life (12). Amazingly, the effects are almost immediate. It has also been shown to decrease overall healthcare costs in this patient population through less provider visits, medications, and additional unnecessary workup (13-15). Most importantly, SCS can lead to reduced dependence on opioids with >80% of implanted patients requiring maintained or lower levels of opioids (16). In a recent study, spinal cord stimulation was able to allow nearly 80% of study patients to stop opiate medications entirely (17). At a time when opioid use is far too prevalent and healthcare costs are increasingly high, this growing technology could assist in providing a more favorable treatment alternative.
Chronic pain affects more than 100 million Americans and creates more than $600 billion in healthcare costs and lost productivity nationwide. It is one of the most common chief complaints encountered in medical offices. Our prior reliance on opioid medications for chronic nonmalignant pain has led to more than 100,000 avoidable overdose deaths (18). Through the use of SCS and a multidisciplinary approach, the field of interventional pain medicine is leading the charge to fix the opioid epidemic.
For more information regarding SCS, please visit the International Neuromodulation Society’s (INS) website or the Neuromodulation journal, the official journal of the INS.
This article was written with guidance from Timothy Deer, MD.
- “Opioid Overdose.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 16 Dec. 2016, www.cdc.gov/drugoverdose/data/statedeaths.html.
- Opioid Overdose.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Aug. 2017, www.cdc.gov/drugoverdose/data/prescribing.html.
- Cicero TJ, Ellis MS, Surratt HL, et al. The changing face of heroin addiction in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7)821-826.
- Porter J and Jick H. Addiction Rare in Patients Treated with Narcotics. NEJM. 302(2):123.
- Portenoy R and Foley K. Chronic Use of Opioid Analgesics in Non-Malignant Pain: Report of 38 Cases. Pain. 1986;25:171-186.
- Van Zee A. The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy. Am J Public Health. 2009;99(2):221-227.
- Kapural L, Yu C, Doust MW, et al. Novel 10-kHz High-frequency Therapy (HF10 Therapy) Is Superior to Traditional Low-frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain. Anesthesiology. 2015;123:851-860.
- Deer TR, Mekhail N, Provenzano D, et al. The Appropriate Use of Neurostimulation of the Spinal Cord and Peripheral Nervous System for the Treatment of Chronic Pain and Ischemic Diseases: The Neuromodulation Appropriateness Consensus Committee. Neuromodulation. 2014;17:515-550.
- Baber Z and Erdek M. Failed back surgery syndrome: current perspectives. J Pain Res. 2016;9:979-987.
- Thomson S. Failed back surgery syndrome-definition, epidemiology, and demographics. Br J Pain. 2013;7(1):56-59.
- Walid MS, Hyer L, Ajjan M, Barth AC, and Robinson JS Jr. Prevalence of opioid dependence in spine surgery patients and correlation with length of stay. J Opioid Manag. 2007;3(3):127-128.
- Kumar K, Taylor RS, Jacques L, et al. The effects of spinal cord stimulation in neuropathic pain are sustained: a 24-month followup of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery. 2008;63(4):762–770.
- Kumar K, Taylor RS, Jacques L, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: A multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain. 2007;132:179-188.
- Zucco F, Ciampichini R, Lavano A, et al. Cost-effectiveness and cost-utility analysis of spinal cord stimulation in patients with failed back surgery syndrome: results from the PRECISE study. Neuromodulation. 2015;18(4):266–276.
- Kumar K and Rizvi S. Cost-effectiveness of spinal cord stimulation therapy in management of chronic pain. Pain Med. 2013;14(11):1631–1649.
- Lad SP, Petraglia FW, Kent AR, et al. Longer delay from chronic pain to spinal cord stimulation results in higher healthcare resource utilization. Neuromodulation. 2016;29(10):12389.
- North R, Kidd DH, Farrokhi F, et al. Spinal Cord Stimulation Versus Repeated Lumbosacral Spine Surgery for Chronic Pain: A Randomized, Controlled Trial. Neurosurgery. 2005;56:98-107.
- Al-Kaisy A, Palmisani S, Smith TE, et al. Long-Term Improvements in Chronic Axial Low Back Pain Patients Without Previous Spinal Surgery: A Cohert Analysis of 10-kHz High-Frequency Spinal Cord Stimulation over 36 months. Pain Med. 24 Oct 2017. Epub ahead of print.
- Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011.
About the Authors
Jon Hagedorn, MD, is a CA-3 anesthesiology resident at Baylor College of Medicine in Houston, TX and a member of the International Neuromodulation Society (INS) Public Education, Outreach, and Website Committee. Timothy Deer, MD, is the current President of the INS and has authored 100+ articles on interventional pain management.