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Aug. 14, 2019

By Vartika Atrey, MD
USMD Denton North Clinic
Denton, Texas

It’s hard to go a day without reading a headline or hearing a news story about “the opioid crisis.” Awareness about the dangers of addiction to prescription opioid pain medications is now front and center—and for good reason. The National Institute on Drug Abuse reports that 115 people in the United States die every day from an opioid overdose.

How did this happen?

Twenty years ago, pain medications weren’t considered addictive.
In the 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers. Now it’s clear that is not the case. Nearly 29 percent of patients prescribed opioids for chronic pain misuse them. In fact, prescription pain medication overdose is now one of the most frequent reason for emergency room visits—up a dramatic 30 percent from 2016 to 2017. And the increase is being seen from coast to coast, among both men and women.

All of this has made care providers especially cautious about prescribing pain medications. In 2016, the Center for Disease Control published recommendations on opioid management of chronic pain—prompting primary care physicians to take a close look at crisis.

“It’s a huge topic of discussion now,” says Vartika Atrey, a family medicine physician at the USMD Denton North Clinic. Not only among physicians, but also among physicians and their patients because pain—particularly back pain—is one of the most common health complaints we see every day in our practice.”

Conservative options are the first line of treatment.
Whether you suffer from lower back pain, neck pain or arthritic pain, conservative treatment options are usually the first course of treatment. “I like to begin by having a conversation with patients to determine whether their pain is a dull, constant ache or a sudden, sharp sensation. Most low back pain is short term and lasts a few days to a few weeks. It tends to resolve on its own with self-care without any loss of function. That’s why before we even consider pharmacological treatment, I first recommend conservative treatment options. Exercise—especially stretching—physical therapy, massage therapy, topical medication and oral over-the-counter medications along with heat and ice therapy can be used safely and effectively at home and have been shown to help with pain.”

Dr. Atrey’s approach is in line with clinical recommendations recently published by the American College of Physicians (ACP). In 2017, the ACP developed guidelines for the noninvasive treatment of low back pain after reviewing the results of clinical trials on pharmacologic and nonpharmacologic treatments for both acute and chronic low back pain (pain that persists 12 weeks or longer). Treatment outcomes evaluated in their review included the reduction or elimination of low back pain, improvement in back function and health-related quality of life, reduction of disability, number of back pain episodes, time between episodes, patient satisfaction, and adverse effects. ACP’s findings reinforce the strong case for nonpharmacologic management of pain.
“That’s why it’s important to talk with your doctor about any pain you may be having,” Dr. Atrey says. “As physicians, especially primary care physicians, we’re here to educate our patients and engage in discussions that explore conservative treatment options.”

Coping with chronic pain.
Even for individuals who suffer from chronic pain, there are good treatment options other than prescription pain medications. “But before we decide on an appropriate regimen, it’s important to understand what the treatment goal is. Along with reducing the intensity of their pain, is the goal to help the person return to work? Improve their range of motion? Knowing the goal helps inform our course of action.”

Conservative treatment options for chronic pain can include acupuncture, spinal manipulation, yoga and deep tissue massage.

Studies by the National Center for Biotechnology Information (NCBI) have shown that acupuncture is just as effective as over-the-counter pain medications and some anti-inflammatory medications commonly prescribed for chronic back pain,” adds Dr. Atrey.

Spinal manipulation
“Spinal manipulation includes exercise such as stretching, massage, and physical therapy,” Dr. Atrey explains. “Patients may use one or a combination of all three. Clinical trials have shown that spinal manipulation can be as effective in managing pain as prescription medications.”

Pain management doesn’t just involve the physical and mechanical aspects of pain. Your brain is intimately involved in signaling pain and stimulating natural pain-relieving opiate neurotransmitters (endorphins, dynorphins and enkephalins) that relieve pain. That’s why it’s important to engage your brain in managing pain. Along with gently stretching and strengthening your body, the meditative aspect of yoga helps you harness your mind to reduce pain.

“Yoga is based on principals that incorporate physical, mental and spiritual well-being, so it addresses the neurological as well as the psychological aspects of pain,” says Dr. Atrey. “Studies have shown that levels of serotonin (a neurotransmitter linked to pain and depression) and cortisol (a hormone that can cause stress and heighten the feeling of pain when your body produces too much) are positively affected by yoga.”

There are many different modalities of yoga, so it’s important to check with your physician before trying one. “Understand the intensity and duration of the various types of yoga, and make sure the one you are considering is appropriate for you,” Dr. Atrey advises.

Deep tissue massage
Using firm pressure and slow strokes to reach deeper layers of muscle and the connective tissue around it, deep tissue massage is used to break up scar tissue, muscle knots and bands of rigid tissue that can disrupt circulation and cause pain, inflammation and limit range of motion.

“Individuals who would like to know more about conservative treatments like acupuncture and yoga can learn more at the National Centre for Complementary and Integrative Health,” says Dr. Atrey.

What happens when conservative treatment doesn’t help?
For individuals whose chronic pain is not well managed with conservative treatments, prescription pain medications may be necessary. However, Dr. Atrey first reviews all over-the-counter and prescription medications patients are taking for other conditions before prescribing any pain medications.
“Before moving into pharmacological management, I always encourage my patients to bring in all the over-the-counter and prescription medications they are currently taking so we can check for any potential adverse drug-to-drug interactions. Some over-the-counter medications shouldn’t be taken in conjunction with prescription medications. This is especially important in seniors. Prescription pain medication may not be compatible with some of the other medications they are taking for other conditions.”

Vartika Atrey, MD, is board certified in family medicine by the American Board of Family Medicine. She earned her medical degree at Stanley Medical College in India. She completed her residency in family medicine at University of Texas Southwestern Medical Center in Dallas, Texas.

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