Non‑opioid pain management

Podcast transcript

INTRO
Welcome to Docs in a Pod presented by WellMed. Over the next half hour, Docs in a Pod will educate you about the health and wellness of adults everywhere. Co-host Dr. Rajay Seudath and Carmenn Miles will share information to improve your health and well-being. And now here are Carmenn Miles and Dr. Rajay Seudath.

CARMENN MILES
Hello, and thank you so much for joining us. I'm Carmenn Miles, your host today alongside veteran co-host Dr. Rajay Seudath on this, the award winning Docs in a Pod presented by WellMed. Each week we come to you with a wide range of health and wellness topics, especially those that impact our seniors. Our goal is to share practical information on how we can all live healthier, happier lives and better manage chronic conditions. We've got a great topic for you today, so thank you again for joining us. My co-host today, as I mentioned, is Dr. Rajay Seudath. He is absolutely no stranger to Docs in a Pod. He is a Tampa, Florida native. Dr. Seudath is a board certified family medicine physician and currently he is lead physician at the University location for Optum. Dr. Seudath is enthusiastic about primary care, and he's always keeping health literacy in the forefront while guiding his patients to meet their health care goals. He's passionate about teaching, and that's just one of the many reasons we love having him as our co-host on the show. Hey, Dr. Seudath, how are you today?

DR. RAJAY SEUDATH
I'm happy to be back. Dr. Raj is back. I was off for a little while, but now I'm here. I'm excited about this topic. It's when we get a lot of.

CARMENN MILES
I know. We haven't chatted since the first week of the year, so welcome, welcome back. Let's take a moment to welcome our guest today. Robert Hernandez is a family nurse practitioner out of San Antonio, Texas. He earned a Master of Science in nursing at the University of Texas at Arlington. Robert says choosing to be a family nurse practitioner offers him the unique opportunity to care for a wide variety of patients. Using an evidence based approach, he empowers his patients to make informed decisions about their health, and he really strives to support the health and well-being of all of his patients, their families, and the San Antonio community as a whole. Outside of work, Robert says he enjoys spending time with his family, playing video games and watching Formula One racing. Hello Nurse Hernandez, and welcome to Docs in a Pod. Are you excited about the Formula One racing season? I think it kicks off this weekend, right?

ROBERT HERNANDEZ, NP
I am.

CARMENN MILES
In Australia, is it?

ROBERT HERNANDEZ, NP
It's going to be in Australia. I'm very excited. Do you watch Formula One?

CARMENN MILES
You know what? You should not be impressed that I know this information. The only reason that I'm aware is because of all of the news coverage, quote end quote, around Kim Kardashian and Lewis Hamilton. So, yeah, don't give me too much credit for knowing.

ROBERT HERNANDEZ, NP
What? I didnÕt know that. Wow, you have more information than I do.

CARMENN MILES
They are a thing. Well, thank you again for joining us. We'll get to more important topics such as pain and how to manage pain with a non-opioid approach. Pain affects millions of people, including myself every day. For years, opioids, Robert, have often been the default solution if you will. But today we want to talk about safer more effective ways to manage pain without relying on opioids. First off, I think it's important that we share with our listeners what we mean when we refer to opioid medications. What do we mean when we say opioid?

ROBERT HERNANDEZ, NP
An opioid is a pain medication, and it's actually derived from opium, which is a poppy plant originally. We've kind of manufactured it and made opium into something that's a little bit more predictable. So, we have medications like hydrocodone and codeine. There are stronger, more synthetic versions of opiates. There's a huge increase in the use of fentanyl now, especially in the street scene. Stuff like that. Anything that targets the MU pain receptors in the brain is typically an opiate.

CARMENN MILES
Very good. When we mention opioids, are there guidelines on maximizing the use of opioids? What are the guidelines? Should we take a non-opioid medication approach before that? Before you answer that question, we're going to take a moment to welcome those who may have just joined us. You're listening to the award winning Docs in a Pod presented by WellMed. I'm Carmenn Miles. Our podcasts are available wherever you listen to podcasts, and we're also available on the radio in several Texas and Florida markets. My co-host today is Dr. Rajay Seudath, along with our guest, Nurse Robert Hernandez from San Antonio, Texas. Today we are discussing pain management, the non-opioid approach. So, we were talking about opioids, what that means, and I was asking about guidelines. Typically, like I mentioned in the intro, for some time, opioids had become the default medication. That may still be the case, but I'm wondering if there are any guidelines on maximizing non-opioid medications before prescribing opioid medications.

ROBERT HERNANDEZ, NP
Yeah, really the stems from the opioid crisis that we're currently in, they kind of stemmed from overprescription of opioids in the mid 90s. It's kind of increased the overdose rate from opioids. So, the newer guidelines, probably within the last several years, are leaning towards utilizing opioids less and opting for either non-pharmacological options or non-opioid options like Tylenol, ibuprofen, other anti-inflammatories. Opioids still have a role in pain management. It's still something to consider, but it's not as first line as perhaps it was in the past.

DR. RAJAY SEUDATH
As Carmenn was saying what's kind of the guideline? I think the word that we would use is stepwise therapy.

ROBERT HERNANDEZ, NP
Exactly.

DR. RAJAY SEUDATH
What are what are the things that we're going through step by step until we get to opioids? Now, there are certain times when we would jump to opioids for like a knee replacement. That's going to be a very, very painful, bloody type of recovery. So, an opioid would be a standard part of that regimen in addition to other things. But that's not going to be forever and ever and ever. That's for a very short, calculated period of time. I think that's exactly what Robert was talking about is previously, you just go get some laudanum from the store and anything that ails you, you take some morphine or you take some sort of opiate derivative. And that's what did it for you. As we're in that crisis now, that's where we're trying to get away from that. This is a very good talk and a very good subject in terms of trying to get away from opioids. What are the other things besides narcotics, besides opiates, besides morphine? What are the things we can do to get away from those? Because they have a lot of side effects.

ROBERT HERNANDEZ, NP
Yes, exactly.

CARMENN MILES
So, the non-opioid therapies, from what I'm understanding, are at least as effective as opioids for many types of acute pain and are preferred for chronic pain. And my accurate in saying that and if so, let's talk about some of the non-opioid options that are out there. Are there different kinds? I'm sure there's not a one drug fits all kind of scenario. Can we tap into that a little bit?

ROBERT HERNANDEZ, NP
Yeah. There are lots of very effective non-opioid medications for acute pain. I mean, I can just name a few examples. Something that we gave in the office here at WellMed is an injection form called Tordol. ItÕs extremely effective. I have seen some documentation that Tordol is just as effective as even morphine in certain cases and certain conditions. For standard exacerbation of low back pain, Tordol is excellent for stuff like that. We also have over-the-counter medications like Tylenol. It's an old drug. It's been around for a long time. It's very effective, especially in older adults, and relatively safely if taken as instructed under the supervision of a healthcare provider. Ibuprofen and Aleve. All these are nonsteroidal anti-inflammatory. Again, relatively safe. Some something we need to monitor if we're going to be on it for long term, although very effective, especially for moderate pain. For severe pain, we kind of get a little bit challenging there. Severe pain or chronic severe pain gets a little challenging. As far as medications go, sometimes we have to increase the dosing and timing of the anti-inflammatories if you want to avoid, using opioids. I don't know if you want to say anything else.

DR. RAJAY SEUDATH
Yeah, sure. Another thing is, sometimes we have to think about how pain is created in the body. So, oftentimes it's some sort of inflammation. So, if we're talking about trying to decrease narcotic use, how can we decrease inflammation in the body? Well, there's only three ways to decrease inflammation in the body. The first one is hot and cold. If you want to decrease inflammation from being produced, you use cold right. So, somebody punches you in the eye, you put a cold steak on your eye to try and limit the amount of inflammation that's going to be created. Once the inflammation has been created, then heat, such as a heating pad or a hot water bottle, you put that on to try and dissipate the inflammation that's been created. So, hot and cold is one way to get rid of inflammation to decrease pain. Two, physical mechanical reduction of the inflammation. So, massaging the area. You can use a vibrating massager, you can do stretching, you can even do light range of motion, certain types of isometric contractions. Those kinds of things are moving the muscles and the joints of the area that's painful to try and mobilize the inflammation that's there. You might hear some people who have back pain, they're like, doc, it hurts whenever I move, but I tell you, if I don't do any movement, it hurts even worse. So, that's the idea of mechanical reduction of inflammation. Then finally we have chemical. A really good anti-inflammatory, so non-steroidal anti-inflammatory, like Robert was saying, NSAIDs, things like Aleve and other medicines to help with inflammation.

CARMENN MILES
Very good. We need to just take a quick break. Please stay with us as we continue this great discussion on the non-opioid approach to pain management right here on Docs in a Pod presented by WellMed.

AD
For over 35 years, WellMed has redefined health care for older adults and people on Medicare. We're physician led and nationally recognized as an Age-Friendly Health System. Our doctors take time to listen and support your unique needs, working with Medicare and select Medicare Advantage plans to keep you healthy and independent. With 24/7 nurse support, telemedicine, in-home, and office visits, care is always within reach. WellMed. Compassionate care. Proven results. Visit wellmedhealthcare.com to learn more.

CARMENN MILES
We're back on Docs in a Pod. I'm your host Carmenn Miles in the chair alongside co-host Dr. Rajay Seudath. Nurse Robert Hernandez is our guest today, and we are discussing how to best manage pain without the use of opioids. One thing I wanted to discuss is the use of steroids versus opioids. Let let's talk about use of steroids and whether or not that's beneficial and whether or not we're still going that route. Is that the safe route?

DR. RAJAY SEUDATH
We were talking about something called NSAIDs. Non-steroidal anti-inflammatory drugs. So, if that's a non-steroid, then what is a steroid? Steroids are very anti-inflammatory. They will cut down the inflammation in your body. Sometimes we give that to a person who has really bad lung disease because they have a lot of inflammation in their lungs. So, we might give them a shot of steroids, then when they come back, they might say, man, that cured my back pain, my knee pain, my shoulders. Everything is so much better. Can I have that every single week? No, we can't because they have a lot of side effects. They can affect your hormones. They can affect your bone density. They can give you stomach ulcers. So, there's a lot of side effects associated with those. Again, non-steroidal pain interventions. Non-opioid pain interventions. We're really trying to get away from those older types of medicines.

ROBERT HERNANDEZ, NP
Exactly. Other than what you mentioned, if you have diabetes, you can increase your blood sugar levels, and it just causes more issues than the pain itself did.

DR. RAJAY SEUDATH
Yep. One of the things that was shown is when they did head to head studies with steroid courses versus NSAIDs like Naproxen or Tordol, the non-steroidal, the NSAIDs, were just as effective as the steroids. So, cutting down on those side effects. The first rule is do no harm.

CARMENN MILES
Are there condition specific medications, or conditions such as migraine or nerve pain, are there non-opioid solutions for these types of conditions? Can we speak to that? I hear about gabapentin and triptans for migraines. Are there non-opioid options for those that are out there and beneficial to some of their listeners?

ROBERT HERNANDEZ, NP
Yeah, migraine treatment is actually one of my favorite things to help people with. They recommend against any opioid for migraines. It's not as effective and is not really treating the migraine at the source. It's just kind of masking the pain. Sometimes, opioids can even cause rebound migraines. You mentioned triptans. Those are great. They target the pathology of migraines. One of the sources. Not all patients are candidates for triptans. If you have heart disease or severe cardiovascular issues, triptans, probably not the best option. There are tons of options, though. Getting into some of the antidepressant class, you have the tricyclic antidepressants that are TCAs for short. There is one called amitriptyline or nortriptyline. They're very commonly used for treatment of migraines. Take it at nighttime. There are SNRIs, which stands for Serotonin-norepinephrine reuptake inhibitors, like Cymbalta. Very effective for migraine prevention. Those are great for my group prevention. Acute migraines do really well with anti-inflammatories. Even acetaminophen respond well for acute migraines. We have these newer drugs out on the market now like Nurtec, which is a CGRP. Those are very effective for acute migraines. They're probably a little bit more specific for folks who can't or have some contraindication to triptans. Those are great. They don't really have any cardiovascular side effects.

DR. RAJAY SEUDATH
Yep. Those medicines, a couple of the new ones, the CGRP medicines, some of them are used for prevention of migraines as well as for treatment of the acute migraine, too. You touched on gabapentin for neuropathic pain. So, people who have migraines can have numbness, tingling electricity. But other causes, like in the legs or in the hands can cause this kind of electricity, numbness and tingling, burning, pins and needles. We call all that type of pain neuropathic pain. So, there are definitely treatments that are not narcotics that can be helpful for that. Gabapentin is one. Another one in the similar class is called Lyrica, which is pregabalin. Those are medicines that can be helpful for that. Then there are other types of medicines that can be helpful for those kinds of things too.

CARMENN MILES
Is there ever an instance where you have a patient come in and says, I'm having neuropathic pain, and I know you prescribed gabapentin, and I've been this medication, for about 30 days now, and I'm just not getting the results that I intended or expected. Would there ever be an instance where you would recommend combining multiple non-opioid opioid strategies to improve outcomes? Or is the next step an opioid or some type of steroid?

DR. RAJAY SEUDATH
I would definitely think combining non-opioid therapies. That's like what we're talking about that stepwise. You don't necessarily have to stop one step to get to the next step. So, for a person who let's say is having sciatica, so they're having inflammation in their spine, they're having pain around those muscles. The sciatica can cause burning and tingling, and it can also cause tightness of that area. So, for that person, if it's very, very severe, let's say their sciatica was from a car accident or from some other sort of traumatic injury. We may give them Aleve, which is an NSAID. We may give them Tylenol. We may give them a muscle relaxer, and we may give them the gabapentin to try and have multiple mechanisms to help with that type of pain.

ROBERT HERNANDEZ, NP
Yeah, exactly.

CARMENN MILES
We talked about physical approaches to pain management. Dr. Seudath mentioned exercise and physical therapy and the difference between icing that takes down the inflammation and manages that. The heat, remind me, does what?

DR. RAJAY SEUDATH
Heat is going to be to dissipate the inflammation. Icing it is going to be trying to prevent more inflammation from being created. That's kind of a general way of thinking about it. It's much more complex than that, but that's a general way of thinking about it for patients. They ask should I ice it? Should I heat it? The answer is always, well, it depends what you're trying to do.

CARMENN MILES
Yeah, and I never know what to do. If you have inflammation, should you alternate? Should you ice and heat or heat and ice? What is your thought?

DR. RAJAY SEUDATH
My general rule of thumb is if the injury is new, like within the first 4 to 5 days, you should definitely be trying to ice it. If it's gone past a week, icing it may not be as effective as using heat to try and dissipate the inflammation that's already been created. Now, that may not be true for someone who has continuing inflammation in their joints. For instance, if it's knee pain because you have bone on bone arthritis, that means every day you're walking, every day you're moving, you're making more inflammation. So, I tend to tell those patients in the morning, I want you to ice it. In the afternoon, I want you to ice it. In the evening when youÕve made all the inflammation you're going to make, I want you to put your heating pads on it to try and dissipate it to get it away. Most people feel that the heat is more soothing than the ice. I have people that won't ice it if even if I told them, it would give them money. They would never ice it because they just hate the feel of the cold. Doc, I moved to Florida for a reason.

CARMENN MILES
These doctors that take the ice plunges in the in the bathtubs, I'm just like, oh my gosh.

DR. RAJAY SEUDATH
ItÕs effective.

CARMENN MILES
Even just the three minutes in those temperatures it's beneficial?

DR. RAJAY SEUDATH
Absolutely. I had a patient who was on high dose narcotics. He was on muscle relaxers. We had him on benzodiazepines, so Xanax to try and help with his contractions in his muscles. He started doing the cryotherapy, like, twice a day, and he got off of all of his narcotics.

ROBERT HERNANDEZ, NP
Wow.

DR. RAJAY SEUDATH
And he was a young guy. He was only in his 30s. One of the things I wanted to touch on was physical interventions. Not necessarily the non-opioid pharmacological stuff, but just physical interventions like acupuncture, physical therapy, massage therapy, even some manipulations from the chiropractors can be helpful in certain instances. Those are things that, again, we can't just dismiss them. They have a place when it comes to treating pain. So, I want to make sure that patients are taking that into account. Our listeners need to say, yes, the medicines are important, but the other things as well are also important to keeping your pain levels under control.

ROBERT HERNANDEZ, NP
Yeah. I wanted to go into that a little bit more. Physical therapy is excellent, especially for joint pain. Not only helping with pain but also helping with function and mobility. Acupuncture has pretty strong evidence for chronic pain relief. It's more kind of adjunctive, but some folks really get great relief with that. Then maybe going a different direction here, but I think it's helpful for people to understand when you have a lot of pain, it's kind of hard to realistically eliminate all your pain. So, just having realistic expectations about how to control your pain and what level of pain work is acceptable should also be important.

CARMENN MILES
Well, believe it or not, the time really does fly. This has been a wealth of information, and I want to thank you both for your contributions to this conversation about non-opioid approaches to pain management. That's all for today's episode of Docs in a Pod presented by WellMed. Thank you again for joining us. We hope that you have some great takeaways from today's chat. You can catch Docs in a Pod on the radio and several Texas and Florida markets and on any podcast platform. Thanks for hanging out with us today. Until next time, stay well.

OUTRO
Executive producer for Docs in a Pod is Dan Calderon. The producer is Cherese Pendleton. Thank you for listening to Docs in a Pod presented by WellMed. Be sure and listen next week to Docs in a Pod presented by WellMed.

DISCLAIMER
This transcript is generated using a podcast editing tool; there may be small differences between this transcript and the recorded audio content.

Docs in a Pod airs on Saturdays in the following cities:

• 7 to 7:30 a.m. CT – San Antonio (930 AM The Answer)
• 7 to 7:30 a.m. CT – DFW (660 AM, 92.9 FM [Dallas], 95.5 FM [Arlington], 99.9 FM [Fort Worth])

Docs in a Pod also airs on Sundays in the following cities:

• 1:30 to 2 p.m. ET – Tampa (860 AM/93.7FM)
• 5 to 5:30 p.m. CT – San Antonio (930 AM The Answer)

Public health education Podcasts