Jean Mercer, 67, of Bucksport suffered for five years with debilitating pain that started with a bulging lumbar disc. She first noticed a tingling and loss of sensation in one leg, then shooting pain and a loss of control over her foot as the disc deteriorated.
An eight-week course of steroid injections didn’t help. Surgery to remove the disc and fuse the adjacent vertebrae, followed by months of physical therapy, left her with no feeling in her hip and upper leg while the pain in her lower leg was unabated.
“All my activities just stopped,” the longtime teacher and Zumba enthusiast said in a recent interview. “I couldn’t sit in a kayak or walk out the camp road. I couldn’t have sex with my husband. I couldn’t do anything with my grandchildren. I couldn’t even lean over to brush my teeth.”
Over-the-counter pain medicines such as Advil and Alleve took the edge off her pain, but she was taking so much it started to affect her kidney function. Despite the intensity of her pain, she was unwilling to try stronger, opiate-based medicines such as OxyContin, aware of the dangers of addiction, the potential for theft and the common side effects of drowsiness, nausea and severe constipation.
Finally, at the urging of her daughter, Mercer scheduled an appointment with Dan Myerowitz, a chiropractor in Holden. On that first appointment, she could barely make it through the door to his office. But after a half-dozen treatment sessions, which included traditional, hands-on adjustments of her spine and pelvis as well as chiropractic acupuncture, her pain had diminished dramatically and her mobility was much improved.
“It was a gift,” she said, her eyes filling with tears. “I had been so desperate. I couldn’t believe I was in so much less pain, so quickly.”
Alternatives to opioids
As Maine and the nation grapple with growing rates of opioid abuse and addiction, pressure is falling on doctors and other prescribers to change the way they manage patients with chronic pain. While two bills pending before the Maine legislature would make some changes mandatory, many health care providers say they already make a point of steering patients away from opioid medications and toward more comprehensive management of the underlying causes of their pain.
“Our model is to treat pain as a symptom, not a diagnosis,” Dr. Ben Zolper, founder and medical director of Northeast Pain Management in Bangor, said. He has practiced pain management in Bangor for 23 years.
For most of Zolper’s patients, especially those in midlife or older, the underlying diagnosis is back injury, shoulder injury or joint dysfunction. Often, though not always, these are related to a lifetime of working in Maine’s iconic employment sectors: fishing, farming, logging, papermaking and other activities that require heavy lifting, long hours and proximity to heavy equipment.
Zolper aims to restore his patients to functional lives, including getting back to work and maintaining family relationships and commitments. Instead of prescribing addictive opioid drugs, he typically recommends interventions such as steroid injections, joint fusion and a procedure called rhizotomy that selectively destroys nerve roots. Many, but not all patients, find relief from these strategies. Losing weight and improving overall fitness also can help considerably, he said.
Zolper said only about 10 of the many patients under his care are being treated with opioid painkillers. He points out that existing rules developed by the Maine Board of Licensure in Medicine govern the use of opioids and require a doctor-patient contract, random urine tests, pill counts and other measures designed to minimize the potential for abuse. These rules protect patients and prescribers, he said, and should be strictly observed and enforced.
Naturopathic doctor Sarah Kotzur, who practices in Portland, also manages patients with chronic pain. Many of her older patients suffer from wear-and-tear osteoarthritis and autoimmune disorders such as rheumatoid arthritis and fibromyalgia.
“Their pain can be really debilitating,” she said.
Naturopaths, like MDs, attend at least four years of medical school after earning a bachelor’s degree and are well-versed in current medical science, Kotzur said.
“The main difference is that naturopaths believe in the healing power of the body to right itself,” she said.
She uses dietary changes, herbal supplements and homeopathic remedies to reduce the inflammation associated with joint pain and injury, along with physical manipulation and counseling.
Adjunct therapies such as massage and reiki also may be helpful, she said, but can make it hard to tell when naturopathic treatments are really helping.
Kotzur acknowledged the approach she uses takes time to work. But, she said, “we see some pretty incredible results.” Her patients are generally characterized by a willingness to experiment and a mistrust of mainstream medicine. Even so, sometimes they become impatient with slow progress and the continued presence of pain in their lives.
“I remind them, ‘It took you a while to get to this point; you can’t expect overnight relief,’” she said.
With a focus on improving function after stroke, spinal injury, amputation and other traumas, the medical specialty of physiatry also provides a model for managing pain without resorting to opioids.
From physical therapy to rhizotomy to injections of a synthetic medication based on sea-snail venom, Augusta physiatrist James Wilson said, his practice aims to help people “maximize their lives and their ability to seek self-fulfillment.” Opioids typically are used only when other options fail.
Physiatry interventions also include physical manipulation, soft-tissue treatment and relaxation techniques. Non-opioid painkillers include over-the-counter medicines such as Tylenol and ibuprofen. Anticonvulsant drugs may quiet over-irritated nerve endings, and some antidepressants are effective against arthritis and fibromyalgia.
When alternative therapies don’t work
For some, opiates remain the solution that works.
One of Wilson’s patients is a woman in her 50s named Jo, who asked to be identified only by her middle name. She’s suffered from lower back pain most of her adult life. When she was in her mid-40s, it started to worsen, with burning pain shooting through her hip joints and down both legs most of the time. She was determined to tough it out. Women in her family had a history of back troubles.
“I thought it was just part of getting older,” Jo said.
Eventually, a diagnostic exam revealed the problem: advanced osteoarthritis, osteoporosis and progressive deterioration of the discs in her spinal column.
“My doctor was flabbergasted at the amount of damage,” Jo said.
She launched upon a long course of medical consultations, surgeries and procedures to relieve her pain and reclaim her active life. Over the course of four years or so, she underwent nerve blocks, epidural injections, steroid treatments and fusions of the crumbing bones in her neck and back. Her spinal damage worsened. Her pain rapidly became more severe.
“I had no idea pain like this even existed,” she said.
Always an active participant in her workplace, her community and her family, she started spending more and more time in her recliner.
More than once, her primary care doctor offered to write a prescription for a strong opioid painkiller. She refused.
“I was not going to take opiates,” Jo said. “I did not want to be the kind of person who relies on medication to get up and live my life.”
She knew enough about opioid drugs to be afraid of them — the potential for abuse and addiction, the possibility of having them stolen, the unpleasant side effects. She wanted nothing to do with all that, for herself or her family.
But finally, reluctantly, after connecting with Wilson and working through all her other options, she agreed to try an opioid patch for the debilitating pain that threatened to immobilize her forever. The painkiller crosses from the patch through her skin and into her bloodstream at a steady rate. A secondary oral medicine eases her over any rough spots. She is experiencing few side effects. She calls the patch a lifesaver.
The key, she said, was finding a doctor who understood her priorities and was willing to work with her systematically to rule out other options. When it became clear those other options would not work for her, it was easier to accept the opioid painkiller they both hoped to avoid.
“I fought this for so long,” she said. “I really cannot tell you what a difference it has made. Before, I couldn’t do anything. Just walking was excruciating. Now I’m going to the office, playing with my grandkids, cooking supper, doing laundry.”
She gave a small laugh.
“Who would think it could be such a pleasure just to do the laundry?”
