As additional alternative therapies to treat pain such as tetrahydrocannabinol (THC) and cannabidiol (CBD) become available to patients in the United States, we as a nation may begin to decrease our dependency on opioids to treat chronic pain.
In an interview with HCPLive®, Tobias MoellerBertram, MD, chief medical officer of Desert Clinic Pain Institute, explained what opioids’ future role will be in treating acute pain and how alternative therapies could be especially utilized in treating chronic pain.
HCPLive: How likely is it in the next 5 to 10 years that we will find alternative treatments for pain that will reduce dependency on opioids?
Moeller-Bertram: I believe it is actually very likely— mainly because we have to. If you look at the current situation, I think that the understanding of pain that we have based on decades of research is clearly describing an unpleasant sensory and emotional experience, which is driven by biological, psychological, and social factors.
The push right now is to try to integrate these [factors] in a better way to a broader patient population, which will allow us to not focus so heavily on opioids as a treatment.
HCPLive: What are some of the alternative therapies for pain in the pipeline that you are particularly excited about?
Moeller-Bertram: When you talk about different molecules or medications, I believe the reemergence of interest in the medical cannabis and medical hemp space will be exciting. We have a lot of evidence that the phytochemicals out of the cannabis plant have positive effects on a variety of unpleasant states that we see in our patient population.
[These phytochemicals help] the perception of pain, to start. There is also good evidence in the inflammatory arena, and associated symptoms like anxiety or sleep issues seem to be positively affected by these compounds as well.
That, combined with the very positive safety profile, I think is exciting. Several hundred different phytochemicals and more than 100 different cannabinoids are in the flower of the plant. I think the more we understand it, and [understand] the combinations and the effects of the combinations, the better we’re going to be able to use these products for pain management.
But besides a molecule or a medication-based approach, I believe the push toward integrating different services and different disciplines to treat pain will continue. And that is, in my opinion, the best chance that we have to really make a meaningful impact on the lives of patients with chronic pain, because we simply have a biopsychosocial problem.
HCPLive: Do you believe we are treating either acute pain or chronic pain correctly? Which kind lends itself more to the successful use of alternative therapies?
Moeller-Bertram: I’ve been an anesthesiologist and dealt with acute pain in the operating room setting for a long time. If you look at acute pain management, I believe we have the appropriate tools [in place and] we have the appropriate understanding of the nociceptive-driven experience of pain.
Compounds like opioids, anti-inflammatories, and local anesthetics are very powerful in disrupting the nociceptive pathway and thereby reduce the experience of acute pain. I also believe the current tools that we have in the toolbox are probably more appropriate for acute pain.
Having said that, acupuncture alternative therapies can definitely have an impact on the acute pain experience. When you look at the chronic pain phenomenon, we have too heavy an emphasis on medications at this point, in my opinion. This is because the drivers of chronic pain, as we understand now and are in the process of understanding, are different than the drivers for acute pain.
HCPLive: What are your thoughts on the efficacy of CBD and THC in treating pain?
Moeller-Bertram: It’s an exciting new field. We don’t have the rigorous research that we have around other compounds, particularly when it comes to clinical trials in humans, that allow us to make definite conclusions. But I believe if we just look at the history of the use of cannabis plant in humans for a variety of illnesses, including chronic pain, which spans 7000 years, we have a fairly good understanding of the empiric efficacy.
HCPLive: As we continue to improve our research and understanding of alternative therapies and test their efficacy, how do you think the role of opioids should evolve?
Moeller-Bertram: I believe that the role for opioids in acute pain is established and will continue to be used there. In the perioperative or trauma setting, [opioid medications are] a wonderful tool, and if they are used in that setting, they will continue to have a role.
When you look at chronic pain, [however,] I believe that the role of the opioids will be diminished over time. We have enough evidence at this point to know that the positive effects that we have observed in the acute pain setting didn’t hold true for the chronic pain setting, although we hoped they would.
And now, the awareness of the opioid-crisis–related deaths really tipped the balance on the risk-benefit ratio when it comes to opioids. We [should be much more careful in] using them as an additional tool for chronic pain patients.
HCPLive: Will we be able to quantify it someday, and if so, will that help improve treatment regimens?
Moeller-Bertram: This is obviously only my opinion, but I don’t think that we’re going to be successful in having an objective measure of pain, similar to being able to measure blood pressure, [for instance.]
The reason is that pain is a complex, emotional experience. [When an] individual’s brain gets sensory information, its interpretation is affected by a variety of individual factors: upbringing, genetics, and prior experience, [to start].
Having said that, I believe that if we were not focusing so much on giving pain a numerical value where you rate your pain, and we got a little more sophisticated, we could go a layer deeper and ask a patient, “How much is this pain affecting your emotional well-being, your ability to live the life the way that you want to?”
We really should try to focus more on those questions, and then also [create] our treatment plan to be tailored toward which [specific] areas are affected by the pain. [In that way,] I believe we will do much more in our patients’ service than if we were to try to define a better objective scale.