Erin Krebs, MD, MPH, chief of general internal medicine at the Minneapolis VA and a professor of medicine at the University of Minnesota
MINNEAPOLIS, MN – How post-operative pain is treated has changed at the VA, as research has demonstrated that opioids and nonopioids work comparatively well when it comes to relieving pain, with nonopioids having less serious adverse effects and much lower chance of addiction.
Much of this research has been under the guidance of Erin Krebs, MD, MPH, chief of general internal medicine at the Minneapolis VA and a professor of medicine at the University of Minnesota. Krebs has been focused on opioids and the over-reliance on them by physicians her entire medical career.
“I started medical school in 1996, the year that oxycontin was approved,” Krebs explained. “At first, in my med school lectures, I heard things like, ‘Opioids are best used only in short-term situations, or in hospitalization situations, or at end of life.’ But by the time I was in residency, we were doing things differently. I heard, ‘No, we should use them for more problems. It’s a matter of compassion. We don’t want to ignore pain, so we want to treat it more aggressively.’”
These mixed messages made Krebs curious. What research had been done that had sparked this new willingness to prescribe opioids more widely.
“I was surprised to see that there wasn’t new dramatic scientific knowledge,” she declared. “It was related to new products being available.”
Since then, Krebs has led numerous studies, including ones that show nonopioids treat pain just as well as opioids.
“Until recently there weren’t a lot of clinical trials between opioids and nonopioid medications,” she explained. “Almost all of the trial tended to be these short-term placebo-controlled trials, and most pain meds work better than placebo. What was lacking was comparison.”
In a ground-breaking study published in the March 2018 issue of JAMA, Krebs detailed the results of the SPACE Randomized Clinical Trial. The study, which recruited 240 veterans from the Minneapolis area, compared pain relief in opioids with pain relief in acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDS). 1
The study found that, for chronic pain, the two types of drugs worked equally well for pain relief, with adverse effects being significantly more common in the opioid group.
“[This study] was for chronic long-term pain, but other investigators have similarly done trials comparing opioid and other medications for acute and short-term pain,” Krebs said. “The pretty consistent finding is that it seems opioids aren’t better in most cases for relieving pain. The other tools are just as good.”
Abrupt Adjustment
VA has moved quickly to adapt to the changing recommendations for opioid prescribing, though it’s been an exceptionally abrupt adjustment for physicians.
“For practicing clinicians and patients, it almost seemed like it was overnight we did a complete 180 on the guidance,” Krebs noted. “The rationale for changing guidance has been building, but for many people who weren’t looking at those data everyday, it seemed extremely sudden. Usually changes in medicine are more gradual and people have time to adapt. That wasn’t the case here.”
Today VA’s pain management guidelines list opioids as a drug of last resort in managing perioperative pain. Non-pharmacological and nonopioid medications are preferred, with acetaminophen and topical and oral NSAIDs topping the list.
Meanwhile the research base for pain management is growing alongside the medical advances.
“What I think is really exciting are the advances in anesthesia to do local pain blocks,” Krebs said. “People need far fewer medications overall in the period right around surgery. Which is great. When people are trying to recover, they want to be able to get up and get going without all the grogginess and side effects that medications cause.”
New research has also found that there is an upper limit to the amount of pain that can be relieved, especially perioperatively.
“We need to do a better job of informing patients what to expect after surgery,” Krebs noted. “[Teach them] to use their pain to guide their activity, and what they can do if they have difficulty with pain.”
Pain management, she noted, is never one-size-fits-all. And the challenge is not in developing new drugs, but in better understanding pain and how to combine current therapies to the benefit of individual patients.
“Whether it’s long-term pain or short-term pain, combining treatment is probably the best path to treatment,” Krebs explained. “We’re just starting to understand that.”
- Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872‐882. doi:10.1001/jama.2018.0899
