Organized neurosurgery continues to fight for our ability to provide safe, effective, evidence-based neurosurgical alternatives to manage chronic pain and reduce long-term opioid prescribing.
Amidst a nationwide opioid epidemic, the political climate is tense. There is increasing political pressure on physicians to reduce opioid prescribing in an effort to help resolve this widespread crisis. Unfortunately, patients continue to suffer from undertreated chronic pain. Thus, neurosurgeons are finding themselves thrust into situations where they must effectively treat patients in pain with fewer therapies at their disposal. Fortunately, neurosurgeons, in collaboration with our colleagues in pain management, have been developing new surgical therapies to treat chronic pain that do not depend on the use of opioids. In parallel, neurosurgery has been fiercely advocating for the effective and humane treatment of our pain patients and aggressively defending neurosurgery’s role in health care reform. This dual approach of patient advocacy and evidence creation has allowed neurosurgeons to play a vital role in addressing the opioid crisis in America. As neurosurgeons, we can reduce the dependence on chronic opioids and still effectively treat our chronic pain patients.
Neuromodulation is an effective treatment modality utilized in neurosurgical practice to manage chronic pain and reduce the need for chronic opioid use. A number of high-quality, landmark studies by neurosurgeons and pain colleagues have provided clear evidence of the effectiveness of neuromodulation. The SENZA Trial (1) reports the results of a large, prospective, randomized, controlled trial of high-frequency spinal cord stimulation (SCS) for the treatment of low back and leg pain.
A follow-up study (2) demonstrates the durability of treatment effects after two years. The Accurate study (3) documents the results from a large clinical trial of dorsal root ganglion (DRG) stimulation for trunk and limb pain, while the SunBURST study (4) details the results from a large clinical trial of BURST SCS in the treatment of back and leg pain. Together, these trials represent a profound advancement in the quality of evidence supporting the use of neuromodulation in chronic pain patients. Additionally, and perhaps more importantly, these strategies represent effective neurosurgical treatment alternatives to the use of chronic opioids and allow neurosurgeons to serve a critical role in the mitigation of the opioid crisis in America.
The creation of clinical evidence to support the use of neurosurgical pain management strategies serves a crucial role in advancing the welfare of our pain patients. Patient advocacy by the neurosurgical community, however, is equally important for our patients. Advocacy enhances our ability to serve our patients safely and effectively. Your leaders in organized neurosurgery, working through the Washington Committee, have been active in this mission.
The Inadequate Treatment of Pain in the U.S.
The Institute of Medicine, with involvement of neurosurgeon Ken Follett, issued a report in 2011 entitled “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.” There was recognition then, at the height of opioid prescribing, that pain is inadequately treated in the U.S., with huge individual, economic and societal consequences. Much of the focus of that document was on multimodal therapy and appropriate psychological social treatment of patients in pain (5).
In 2016, the Surgeon General published a perspective in the New England Journal of Medicineentitled, “Ending the opioid epidemic: A call to action (6).” In 2016, the American Medical Association (AMA) offered a statement that physicians should limit prescriptions for opioid analgesics to the lowest effective dose for the shortest duration possible (7). We voiced concern that this could cause patients to turn to illicit drugs and could harm our complex surgical patients. In April 2017, when the Senate introduced a bill, the “Opioid Addiction Prevention Act of 2017,” limiting postoperative opioids to a 7-day supply or shorter, depending on the state, the AANS/CNS Pain Section wrote letters opposing this blanket reduction in postoperative opioids. It was argued that many complex spine and trauma patients would be unduly burdened, if not harmed, by this limitation. These letters were sent to Senators Gillibrand and McCain and to the AMA to represent our surgical voice.
Neurosurgery Getting Involved
Neurosurgeons continue to educate our non-surgical colleagues and the community on evidence-based alternatives to long-term opioid prescribing. Important examples that have been shown to reduce the use of opioids by patients include:
- Perioperative, polyanalgesic therapy (8);
- Surgical options, such as intrathecal pain pumps (9); and
- Lesioning procedures (10).
Unfortunately, some organizations have advocated against these strategies claiming there is inadequate evidence supporting them. In early 2017, the American College of Occupational and Environmental Medicine (ACOEM) circulated their “Practice Guidelines: Opioid External Review.” Statements included Level I evidence against the use of intrathecal drug delivery for non-malignant pain (11). The Joint Pain Section countered with evidence to support a neutral stance on pain pumps, an alternative to long-term systemic opioids. Soon after, ACOEM produced “Practice Guidelines: Chronic Pain External Review” (11), which underreported the evidence supporting neuromodulation. Again, the AANS/CNS Pain Section offered revisions with Level I, II evidence supporting the use of neuromodulation.
Every neurosurgeon who is involved in treating spinal or other pain disorders is acutely aware of the harm that can be done by long-term opioids; however, we cannot abandon the suffering pain patient. Like it or not, changes are coming to the delivery of pain management health care in America, in part through new restrictions being implemented to reduce the use of chronic opioids. Your neurosurgery leadership, rather than observe these changes from the sidelines, have played a critical role in the reshaping of the health care landscape.
Neurosurgeons are vastly outnumbered by medical colleagues (many non-surgical) advocating against the interests of those patients requiring neurosurgical treatment. We continue to “punch above our weight class” and effectively advocate for the rights for our pain patients. Neurosurgeons have contributed the necessary evidence and then leveraged this to allow our patients the benefits from these therapies while reducing their dependence on chronic opioids. Neurosurgical awareness and involvement in this opioid epidemic is essential, both for our patients and our specialty. We hope that our voice represents that of all neurosurgeons, regardless of subspecialty, and that we all come together to make a meaningful difference in our communities, nationally and globally.
1. Kapural, L., Yu, C., Doust, M. W., Gliner, B. E., Vallejo, R., Sitzman, B. T., . . . Burgher, A. H. (2015). 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, 123(4), 851-860.
2. Kapural, L., Yu, C., Doust, M. W., Gliner, B. E., Vallejo, R., Sitzman, B. T., . . . Burgher, A. H. (2016). Comparison of 10-kHz high-frequency and traditional low-frequency spinal cord stimulation for the treatment of chronic back and leg pain. Neurosurgery, 79(5), 667-677.
5. Institute of Medicine of the National Academies. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington D.C.: The National Academies Press.
9. Deer, T. R., Hayek, S. M., Pope, J. E., Lamer, T. J., Hamza, M., Grider, J. S., . . . Mekhail, N. (2017). The polyanalgesic consensus conference (PACC): Recommendations for trialing of intrathecal drug delivery infusion therapy. Neuromodulation: Technology at the Neural Interface, 20(2), 133-154.
10. Neurosurgical Guidelines for Cancer Pain, in progress.