Treating the Root of the Opioid Epidemic
Dr. Calvin Johnson
Despite the increased national attention to prescription painkiller abuse, the opioid crisis continues to rage through the state of Oklahoma with little sign of stopping. Although awareness of the problem is important, this issue will not be solved until we collectively address the root causes and identify alternative ways to treat pain.
According to U.S. Drug Enforcement Agency (DEA) 2017 reports, the state of Oklahoma ranked 6th in the nation for oxycodone sales (1) and 2nd in the nation for hydrocodone sales per capita (2). Oklahoma residents also experienced higher rates of opioid overdoses in comparison to neighboring states. In 2017, the age-adjusted rate of drug overdose deaths involving prescription opioids (per 100,000 population) in Oklahoma was 6.7, compared to 2.3 in Texas and 4.1 in Missouri (3). During that same year, more than 250 people died from opioid overdose in Oklahoma (3), which is more than the 239 homicides reported in the state (4).
Prescription painkillers are now the most commonly prescribed class of medications. Much of the rampant opioid abuse stems from the extensive availability of these medications, which are widely diverted and improperly used (5). Opioid analgesics have become a treatment of choice to relieve various types of acute pain, improve function and, more disturbingly, manage chronic pain. While opioids provide effective short-term pain relief, they do not address the underlying causes of pain.
Around 3-4% of the adult population (between 9.6 to 11.5 million Americans) are prescribed opioids for longer-term pain relief, many of whom will become dependent on these drugs (5). In 2017, the Centers for Disease Control and Prevention (CDC) reported that more than 35% of all opioid overdoses involved prescription drugs. The drugs primarily involved in prescription opioid deaths include methadone, oxycodone and hydrocodone (6). Although the average U.S. rate for opioid prescriptions in 2015 was 70 per 100 persons, Oklahoma providers wrote 101.7 opioid prescriptions per 100 persons in the same year (7).
Knee problems represent one of the most common sources of chronic pain. Patients in the U.S. undergo more than 600,000 total knee replacements per year. Of these patients, many are prescribed long-term courses of opioid analgesics before and after surgery (8). Genicular nerve radiofrequency ablation, also known as genicular nerve blocks, may provide a therapeutic alternative to reduce chronic knee pain in patients with osteoarthritis, those with failed knee replacement or those who want to avoid surgery.
The process targets the genicular nerve around the knee and heats it up with an electric current until it stops sending pain signals. It’s a precise procedure that doesn’t affect the tissue outside of the nerves. This procedure is useful to treat knee pain, both chronic and acute, without the need for risky opioids.
Although opioids may provide relief from knee pain for several hours, genicular nerve blocks work to block the nerves that transmit pain from the knee for longer periods of time. Many patients are on painkillers the day of their knee surgery to manage their pain. Yet, after knee surgery, it has been reported that approximately 40% of patients are still on opioid analgesics six months later (9). Radiofrequency ablation of genicular nerves, on the other hand, may provide pain relief over an extended period of time. According to a chart review performed by Iannaccone et al, it was found that the genicular nerve block procedure may provide, on average, greater than 60% pain relief in patients for as long as six months (10).
I have first-hand experience with genicular nerve blocks both as a doctor and a patient. I once tore my meniscus and was scheduled for a knee replacement, but I could not have the surgery right away. As an alternative, I had the genicular nerve block procedure performed in both of my knees, and the pain subsided for nearly a year. I had the procedure done again and then went in for knee surgery. After the knee surgery, I took pain medication for only three days — a far cry from millions of Americans that turn to long-term use of opioids for chronic pain management.
I know many patients with similar stories. These individuals have taken opioids for extended periods of time or suffered through their pain for years with no end in sight. Instead of turning to opioids and fueling a crisis that has wrecked communities across the nation, it is my hope that Oklahomans will look into alternative treatment options for their injuries and pain.
Dr. Calvin Johnson is the founder of Oklahoma Sports Science and Orthopedics.
U.S. Drug Enforcement Agency’s Automated Reports and Consolidated Ordering System (ARCOS) Retail Drug Summary Reports. State Health Access Data Assistance Center (SHADAC) analysis of prescription opioid painkiller sales in kilograms per 100,000 people, oxycodone and hydrocodone. Retrieved from: http://statehealthcompare.shadac.org/rank/170/prescription-opioid-painkiller-sales-in-kilograms-per-100000-people-by-oxycodone-and-hydrocodone#1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52/87/24/204/false/highest
U.S. Drug Enforcement Agency’s Automated Reports and Consolidated Ordering System (ARCOS) Retail Drug Summary Reports. State Health Access Data Assistance Center (SHADAC) analysis of prescription opioid painkiller sales in kilograms per 100,000 people, oxycodone and hydrocodone. Retrieved from: http://statehealthcompare.shadac.org/rank/170/prescription-opioid-painkiller-sales-in-kilograms-per-100000-people-by-oxycodone-and-hydrocodone#1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52/88/24/204/false/highest
Scholl L et al. Drug and Opioid-Involved Overdose Deaths – United States, 2013-2017. Morbidity and Mortality Weekly Report. ePub: 21 December 2018. Retrieved from: https://www.cdc.gov/mmwr/volumes/67/wr/mm675152e1.htm?s_cid=mm675152e1_w
Federal Bureau of Investigation Uniform Crime Reporting System. Murder by State, Types of Weapon, 2017. Retrieved from: https://ucr.fbi.gov/crime-in-the-u.s/2017/crime-in-the-u.s.-2017/tables/table-20
Volkow N and McLellan A. Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies. N Engl J Med. 2016; 374:1253-1263. Retrieved from: https://www.nejm.org/doi/full/10.1056/nejmra1507771#article__s004
Centers for Disease Control and Prevention. Prescription Opioid Data. Retrieved from: https://www.cdc.gov/drugoverdose/data/prescribing.html
National Institute on Drug Abuse. Opioid-Related Overdose Deaths. ePub: February 2018. Retrieved from: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/oklahoma-opioid-summary
Martin G et al. UpToDate. Total Knee Arthroplasty. Surgery by the Numbers. September 2018. Retrieved from: https://www.uptodate.com/contents/total-knee-arthroplasty
Goesling J et al. Trends and predictors of opioid use following total knee and total hip arthroplasty. Pain. 2016; 157(6):1259-1265. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868627/
Iannaccone F et al. A review of long-term pain relief after genicular nerve radiofrequency ablation in chronic knee osteoarthritis. Pain Physician. 2017; 20(3):E437-E444. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/28339444