For many years, effectively managing post-surgical pain for patients has taken the form of a prescription for an opioid. The dose and the duration are based on general dosing guidelines, clinical outcome data and patient feedback about their pain.

While opioid prescriptions are an extremely effective way to alleviate pain, the potency and potential for misuse of these substances is resulting in unprecedented addiction. In fact, deaths from prescription opioids have more than quadrupled since 1999. To counteract this trend, physicians and health care organizations must be open to innovation and technology for non-opioid alternatives for pain management.

In the recent webinar, “Exploring Pain Management Alternatives,” Joe Cummings, senior associate, technology assessment at Vizient, offered his analysis of 10 categories of innovative approaches to pain management. He bases his analysis on a review of all available clinical literature associated with a technology to determine its effectiveness, costs and barriers that may affect implementation.

“After looking at the scope of medical device-based research around pain management, it’s clear to me that innovations are emerging that can address many aspects of the opioid epidemic problem,” Cummings said. “The challenge with innovation is overcoming the barriers to technology adoption that work to maintain the status quo. For example, the speed and severity of the opioid epidemic may require us to be willing to explore pain management alternatives with less clinical evidence than we would usually accept.”

Of the pain management technologies currently available in the market, Cummings highlighted genetic testing and neuro-analgesia as two innovations he believes are ready for more widespread adoption by physicians for the treatment of pain.

Genetics and pharmacogenomics help deliver the right dose for the right duration

Cummings said the use of genetic tests targeting individualized risk assessment for opioid addiction and personalized opioid therapy is one of the most innovative approaches to combat opioid misuse and addiction. Physicians can now order a genetic test panel that examines genetic markers associated with addiction. Pharmacogenomic tests, called a pre-surgical opioid metabolism panel, can also help plan a customized opioid therapy based on an individual’s genes that determine a drug’s efficacy.  

“With patients receiving the correct and effective dose that’s customized based on their genetic profile, they may avoid inadvertently succumbing to a long-term addiction,” Cummings said.

As far as evaluation, Cummings says the anticipated benefit of genetic testing is large, the technology risk is small and the overall financial impact appears favorable to neutral for providers and payers. In addition, the test is relatively easy for hospitals to implement.

“Based on this evaluation, I recommend physicians accept a lower degree of evidence to move forward in adopting and implementing this technology,” Cummings said.

Neuro-analgesia (local non-opioid agents) for pain management

The second pain management innovation Cummings highlighted that specifically treats post-surgical pain was neuro-analgesia, which involves administration of local, non-opioid agents near targeted nerves. With injections, local anesthetics tend to quickly wear off. But using a pump to deliver the local anesthetic can effectively manage pain for several days.

“What I’ve seen in reviewing the clinical literature is that when using some of the pain pumps that deliver regional or surgical site pain blocks, there’s no need to use opioids at all,” Cummings said. “These pumps are effective, underutilized and have a proven track record for pain management.”

He added that innovative technology is often used as part of a multimodal pain relief paradigm. This might involve pain pumps for acute pain after surgery, thermal or cryoneurolysis, e.g. ablation of a nerve for intermediate duration pain relief, or neuromodulation techniques for chronic pain. Peripheral nerve stimulators, which use small electrodes placed next to targeted peripheral nerves, were highlighted as a rapidly growing area with many new innovative developments. Spinal cord stimulators were noted to be the largest segment of the neuromodulation market and are positioned for rapid growth over the next few years.

While Cummings feels strongly about the value of these new technologies, he also understands that inadequate or non-existent reimbursement for the treatment is an important consideration for hospitals and the patient.

To overcome this barrier, Cummings said providers must begin to educate payers and advocate for their patients for alternative pain management therapies to obtain coverage on a case-by-case basis. In a value-based reimbursement scenario, a focus on the total cost of care may support the incorporation of an innovative technology if it lowers the long-term costs associated with treating a condition.

“Often with the adoption of a new technology, you have to look at the value from a long- term perspective as opposed to the initial upfront cost,” Cummings said. “In addition, the technology may result in substantial cost reduction downstream if it acts to minimize potential for opioid addiction and its associated costs.”

Timing is everything

As an innovative technology strategist, Cummings often recommends that providers strive to be in the early majority phase of the technology adoption curve. Innovators may be the early adopters, but they also accept more risk.

“Rigorous, evidence-based medicine is an important consideration, but it can also present a barrier to implementing innovative technologies,” Cummings said. “You must have an open mind when trying to innovate and be willing to make some concessions. Instead of asking ‘can it work?’, you need to be asking ‘does it work?’ If there is evidence to show that the technology does indeed work, then you’ve adequately accounted for risk.”

To learn more about opioid regulations and prescriber practices, register for our free webinar, “Recognition of Pain and Prescriber Practices across the Continuum,” on Monday, June 19 at 11 a.m. CT.

Published: June 13, 2017