The Future of Alternative Pain Therapies

The need to find alternative therapies to opioids to treat both acute and chronic pain is critical for a number of reasons.

With the population aging and individuals living longer there will be a need to develop new therapeutics that are beneficial for the geriatric population.

In addition, our understanding on the opioid epidemic and the addictive nature of the treatments continues to expand.

In an interview with HCPLive®, Tobias Moeller-Bertram, MD, chief medical officer of Desert Clinic Pain Institute, explained why alternative therapies have been slow to take form, but how our growing understanding on both patients and treatments could lead to some positive changes in the near future.

Moeller-Bertram is the co-chair of the Evolving Approaches in Pain Management conference in San Diego on August 14, which will feature several experts discussing opioid use, alternative options for post-surgical pain, and how to best treat addiction.

HCPLive: Since pain is something that transcends different medical fields, how important is it to bring individuals with different expertise to come together and talk about some of these topics?

Moeller-Bertram: It’s of utmost importance. Pain is something that affects all aspects of human experience. It affects physical, mental and spiritual aspects.

If you look at the different varieties of specialties that enter the pain field and can be certified, to see experts really from anesthesia, focusing more on physiology and better blocking the pain with medicines to psychiatry, which is really more focused on the emotional experience of pain and emotion.

You start with the definition of pain that is a physical and emotional experience. And the whole concept of the biopsychosocial experience really shows that pain is the ultimate combination of whole person care.

So all specialties that are focusing on the physical, mental and spiritual aspect of pain are not only welcomed but necessary to really relieve pain from its origin, but also from the burden of pain and the suffering that comes with it.

A multidisciplinary or transdisciplinary approach is needed for meaningful treatments.

HCPLive: With the population aging in the way that it is, how important is it to come up with some pain alternatives that could help the older population?

Moeller-Bertram: This is a problem that's going to affect a lot of us and not only is the population living longer, I think the hope of living a meaningful life is very high. People want to stay active. people want to stay engaged, and people want to contribute to society.

Finding a means of increasing mobility and quality of life and avoiding the risks of current medications, particularly opioids, I think is going to be very important.

There's some exciting opportunities. We're working closely with our surgical and orthopedic colleagues trying to address osteoarthritis. In general, when you look at the newer evolving therapies, I think there's some hope that some new therapeutics going to be able to reduce osteoarthritis pain, and not have those side effect profiles of opioids.

HCPLive: For cannabis, do we have a firm grasp on what areas it should be used for and what maybe it is less effective for?

Moeller-Bertram: I wish I could give you the answer. I think in a few years, we will be able to do so. I think that we have a sound understanding of the usefulness, I think that the evidence so far, is convincing enough, that is shown it's a good product for pain, in general.

I think that before we even can go to which specific pain areas will respond well to the cannabis derived and treatments, we have to probably get a little bit of understanding of which compounds to watch.

Cannabis has more than 100 cannabinoids and there is something known as the entourage effect, where the combination of different components works differently than each other components alone.

So I think we have to get a little better understanding of what in the plant material having which kind of effects.

And once we can explain that a little bit more, we can see for example, a certain combination is better for reducing inflammation in the body, one could expect that any inflammatory driven pain would respond well to that combination.

If it's something that has a more muscle relaxing combination, one could imagine a therapeutic that consists of these components will be better when it comes to a musculoskeletal pain.

I think it's going to be a combination of clinical data feedback that we get from patients that are taking these medications, indicating for which pain concerns and complaints, it was helpful.

And then us on the other hand scientifically understanding which compounds and combinations of compounds have one effect on the body, and therefore combining them to hopefully, be able to really come up with specific subsets of therapeutics for specific pain indications.

HCPLive: Did the pandemic shed light on any of the gaps that need to be closed in terms of pain management?

Moeller-Bertram: My immediate response would be I can tell you that a substantial portion of my patients in my clinics has realized that what's the dependence on particularly opiate medications meant for them.

Going through the anxiety and making sure that they have access to their medication, which I think wasn't necessarily in front of their mind prior to the pandemic.

A lot of those saw that as a negative rather than a positive because their motivation of not relying on a medication that they have to get on their feet to get because there are withdrawal syndromes and of course increased pain.

Particularly the withdrawal symptoms is something patients didn’t normally report prior to the pandemic. So I think that might be one aspect where people reflect more on do, I really want to expose myself to this living scenario were having access on a regular basis to these medications is not only important for me to treat my pain, but also important for me to avoid withdrawals.

To which degree that's going to translate into the willingness to look at alternatives, or, to which degree is going to make it easier for us to have conversations around reduction and limiting opioids will be seen, but at least that is something that comes to mind initially.

HCPLive: You are also presenting during the meeting about opioid addiction therapy options, how has this field grown in recent years?

Moeller-Bertram: I think this is a field that is continuing to evolve. And we do have options on the medical side, then has been brought more to the forefront, particularly the probuphine type of therapeutics.

The fact that it's easier for physicians to prescribe than at this point, I think has made a big impact.

There’s always room for improvement.

On the non-pharmacological side, I think access to trauma informed care, and really working with patients with addictions on those areas is something that I hope we want to improve on and increase that.

HCPLive: How challenging is it to balance the addictive nature of some of these substances with their medicinal value?

Moeller-Bertram: I think this is an ever-present issue when it comes to treatment. You want to have a beneficiary risk benefit profile; you don't want to expose people to unnecessary risks. Also, the individual nature of how you respond to a pharmacologic compound plays a role here, too.

I think that we probably can learn more about predictive measures and predict the factors who's responding how to certain drugs.

It's not liked every person is responding the same way when it comes to addictive behavior to certain drugs. But I believe that in medicine, we often just think about the average patient, which is not in existence.

Some compounds absolutely have higher potential for addiction than others and we have a pretty good idea about that. But I think the predictive measures when it comes to the individual patients actually taking their medications, there's something that we can learn more, and hopefully, you're going to be able to improve that.

So I hope that we as physicians and healthcare providers will in the future have better towards to increase the benefits and reducing the risk when we are using therapeutics that have a benefit for the patients but also the known problems.

HCPLive: Are we close to achieving the balance needed in treating both chronic and acute pain?

Moeller-Bertram: I hope so. I think it's driven by the understanding that the simple transition of one works for acute pain apply to chronic pain does not work. I think the realization around that is really driving the change in thought process and change in approach of treatment.

I continue to hope that this whole person care and the idea of really individualizing treatment is going to continue, which has to mean that we look more at the circumstances, which person has what disease, for what reasons.

I think the trend is continuing. It's going to take a while, there's a lot of factors involved.

It starts with the healthcare practitioners understanding, the patient's acceptance of the shift in paradigm, and then the insurance apparatus and everything that's behind the reimbursement models and those kind of things to really adapt to that.

It's going to be a process. But I think that we are at the point that we know this, this path has to be walked we there's really no turning away from it. So I hope that every stakeholder in both stays motivated and, you know, takes this path one step at a time. And maybe next year when you ask me, you're going to have more tangible changes already.