Beyond opioids, new era in pain treatment

December 1, 2017

A year and a half ago, Jerry started the pain management routine that has changed his life.

He wakes up every morning around 7 at his home in a Fairfield County suburb and takes a vitamin-sized capsule of cannabis oil.

The tablet takes a few hours to work on the pain that courses through his legs, an ongoing symptom of his arachnoiditis — a pain disorder caused by the inflammation of a membrane that surrounds the spinal cord’s nerves.

While he waits for the medicine to work, he settles into his favorite living room chair with a cup of coffee and watches the “Today” show with his wife and three rescue dogs.

A few hours later, as he attends a meeting for one of the nonprofit boards he sits on, he is not thinking about pain. After once suffering so much discomfort that he turned to illicit painkillers, the improvement is a breakthrough.

“Cannabis is medically real,” Jerry said in a recent interview at his home. “I’m a standing, living example of that.”

His regimen reflects a new era of pain management. Alarmed by the epidemic of opioid abuse that has killed tens of thousands of Americans in recent years, medical professionals are rethinking how they treat pain. They no longer turn first to prescription opioids.

Instead, an array of new treatments such as medical marijuana is emerging, alternatives that are widely seen as carrying less risk of abuse and addiction than medical narcotics. Pre-emptive, long-lasting nerve blocks and other analgesics during surgery are becoming common. New pain drugs on the horizon include CR845, an anti-inflammatory being developed by Stamford’s Cara Therapeutics, just down the street from Purdue Pharma, makers of the now infamous Oxycontin.

Spurred by a growing body of research and a diminishing social stigma, marijuana has gained particular traction as a medical alternative to treating pain.

Compassionate Care Center in Bethel comprises one of nine medical marijuana dispensaries in Connecticut and the only one in Fairfield County. Its patient base has grown tenfold since its September 2014 opening to some 3,000.

“We’re all pioneers in this,” said CCC owner Angela D’Amico. “We’re really setting the path for this whole industry. Connecticut is the first state with a pharmaceutical model for medical marijuana. Just like the medication you buy at CVS, all our products have manufacturers’ labels.”

Getting sober

Jerry’s personal pain journey mirrors the rise and fall of opioids and the recent shift to alternative pain treatments. He agreed to share his story on the condition that certain personal details, such as his last name and hometown, not be disclosed.

Before starting the medical marijuana, Jerry had experienced decades of unsuccessful treatment of his arachnoiditis. The condition likely emerged from failed back surgery he underwent in the late 1970s and primarily affects his legs.

By the mid 1990s, Jerry’s pain escalated to the point that he had to quit his job as a fire investigator at a major insurance company. He could not get enough prescribed opioids such as morphine to dull his discomfort, so he resorted to buying unprescribed painkillers, like Percocet. He drank heavily when he was not on painkillers.

Related: Big pharma’s role in the opioid crisis

Jerry got sober about 20 years ago — he says he has not taken a drink or an unprescribed pill since then. But he would struggle for many more years with inadequate pain management with doctor-approved opioids.

He initially looked skeptically at medical marijuana because he feared it would undermine his sobriety. But the support of his pain-management doctor, wife and AA sponsor convinced him the treatment deserved a try.

Pain and weakness still require him to use crutches to get around, but he is able to enjoy activities such as swimming with his dogs. He also travels; he did most of the driving on a trip he and his wife took in October to Myrtle Beach, S.C.

Jerry said he has not become addicted to the marijuana. The type that Jerry and other CCC patients take is not addictive because it works on non-opioid nerve receptors, according to D’Amico.

“It’s not the pot I used to know from college,” Jerry said. “My experience is not one of getting high, but one of feeling calm and not thinking about the pain.”

Insurance generally does not cover treatment with cannabis, and treatment provided by CCC can run between $250 and $1,500 per month. In some cases, CCC covers all costs for terminally ill patients who are struggling financially.

Rethinking pain management

Use of opioids such as OxyContin, from Purdue Pharma, has tailed off in recent years as medical professionals have become more aware of their risks. The amount of opioids prescribed in the U.S. peaked in 2010 and then decreased each year through 2015, according to data released earlier this year by the U.S. Centers for Disease Control and Prevention. But the opioid prescribing rate in 2015 still ran at more than triple the 1999 rate.

The growing wariness of opioids has created an opening for competitors.

A block away from Purdue’s headquarters at 201 Tresser Blvd., Cara Therapeutics is working on a drug that could challenge the dominance of OxyContin.

Cara’s first product is an anti-pain and anti-inflammatory drug named CR845. It would treat several conditions including back and knee pain.

CR845 would represent a more powerful pain treatment than over-the-counter medications such as Advil, but it would prevent the risk of addiction because it would not act on the brain, said Cara CEO Derek Chalmers.

“By shutting down the nerve activity at the site of injury, it can produce ... anti-inflammatory activity in the absence of a central nervous system brain effect, so you don’t induce euphoria at all,” Chalmers said in an interview at the firm’s headquarters at 107 Elm St. “The drug is entirely non-addicting.”

Cara aims to file its first new drug application with the FDA within the next two years.

Purdue officials also cite efforts to diversify their pain-relief products beyond OxyContin. Among ongoing initiatives, the company has partnered with San Diego-based biotech firm AnaBios to research alternatives to opioids and non-steroidal anti-inflammatory drugs.

Striking a balance

Lawmakers in several states including Connecticut have moved to stanch the flow of narcotics by enacting new restrictions. The General Assembly last year passed legislation that generally prohibits medical practitioners from writing opioid prescriptions for more than seven days to minors or adults who are taking the drugs for the first time.

But doctors warn against overregulation.

“We’ve got to be very careful that legislative efforts that try to deal with the opioid epidemic don’t turn into window dressing about how many pills can be prescribed at a time,” said Dr. Jeffrey Gordon, president of the Connecticut State Medical Society. “That doesn’t get to the root of the problem. We want people who have legitimate pain, as assessed by their doctors, to be able to get the medications, such as opioids, that they might need.”

In hospitals and medical offices, doctors are increasingly turning to alternative pain treatments that can offer patients as much relief as opioids while greatly reducing their risk of addiction. At Stamford Hospital, injectable nerve-block treatments were used last year in about half of orthopedic procedures and 20 percent of other operating-room procedures including hernias, abdominal incisions, breast surgery and pediatric urology cases.

“If you do pre-emptive analgesia, that’s one of the most important things to do,” said Dr. Betty Ann Robustelli, an anesthesiologist at Stamford Hospital, said of nerve blocks. “The nerves aren’t fired up, and it really reduces the post-op pain you see in a lot of cases.”

Dr. Paul Sethi, a Greenwich based-surgeon at Orthopaedic and Neurosurgery Specialists, reported that about half of his patients who undergo shoulder surgeries with the injectable novocaine derivative Exparel are not requiring any narcotics or opioid medications after surgery. The other half need significantly lower amounts of narcotics than they would without Exparel, a local anesthetic injected at the time of surgery that can last up to three days.

“My patients are my teammates in their care,” Sethi said. “I have patients who come in and say ‘I don’t want to want to take these opioid medications.’ And I say ‘OK, let’s talk about it, and let’s explore different alternatives.’ Everyone is in this together.”

Effective responses will not necessarily erase pain or eliminate opioids. When Jerry occasionally experiences “breakthrough” severe pain, he takes a morphine pill. He also has a morphine-dispensing pump implanted in his side.

But his opioid use represents a small fraction of his one-time intake. His face brightens when he reflects on his progress.

“After 20-some odd years of being in bone-crunching pain, not having pain significant enough to remember is big,” he said. “If I don’t think about it, I’m in good shape. I can live again.”

pschott@scni.com; 203-964-2236; twitter: @paulschott