New (and Old) Ways to Battle Pain

One day in early 2008, Israel Andrade, a department manager at a home store in Dallas, was helping move a heavy carpet when he herniated all the lumbar discs in his back. Thus began a seven-year search for relief from chronic pain.

Andrade tried several medications, including the opioid hydrocodone, which left him "too doped up to do anything." Then there was a morphine patch, a lidocaine patch, steroid injections in his back, nerve blocks and three procedures using radiofrequency to destroy pain-carrying nerve fibers. While these treatments do the job for some people, they left Andrade still in so much distress that he couldn't stay in any one position for very long, and a 30-yard walk to the mailbox required medication and hours of rest.

Finally, last year, a doctor recommended a surgical procedure that interferes with nerve signals between the spinal cord and brain. "It's been a godsend," says Andrade, 61, who now walks two miles several times a week. "My pain is nearly gone."

With 1 in 5 Americans suffering from chronic pain, the race is on to rediscover and invent alternatives to opioids. Overdose deaths from all opioids have nearly quadrupled since 1999, to more than 28,000 in 2014, according to the Centers for Disease Control and Prevention. Over half of those deaths were due to prescription medications. Doctors were "giving pain medication for every little sniffle," says Charles Kim, an assistant professor in the department of rehabilitation medicine and anesthesiology at NYU Langone Medical Center in New York. "We've realized now we can't do that anymore."

The push for alternatives has led to new interest in treatments often neglected in the opioid era. Acupuncture, for one, was shown in a 2012 Archives of Internal Medicine study involving some 18,000 patients to provide significant relief for osteoarthritis, headaches and back and neck pain. In the two-hour procedure that helped Andrade, which can alter how the body perceives pain, doctors implanted a device about the size of a deck of cards under his skin and tiny insulated wires on his spine that use low-frequency electricity to interrupt the pain signal. And researchers are also hard at work searching for new and better treatments. Here's a look at some of the most promising nonopioid options, old and new:

Neurostimulation. The technique that helped Andrade has been around since 1967, and can be enlisted almost anywhere in the body to help manage everything from migraines to pain that persists after a person has had shingles.

Probably the most prevalent type relies on devices that stimulate nerves in the spine to treat pain in the back and in the legs and arms, often substituting a gentle tingling called paresthesia. (For headaches, neurostimulation devices might be implanted in the neck or even in the gums.)

Though the technology has been on the market for several decades, the recent surge of innovation in pain management has improved it significantly. The devices are smaller, for example, and battery life has been extended from just a couple of years to as long as 10. Andrade's implant, whose electrical flow he can turn off and adjust via a remote controller, has a sensor that "remembers" what level of stimulation is needed in various body positions and automatically adjusts for movement.

The latest wrinkle: In 2015, the Food and Drug Administration approved the first such device that delivers high frequency stimulation -- up to 10,000 hertz -- instead of the traditional 50 hertz. The high frequency eliminates the tingling feeling associated with these devices, and according to a 2015 study published in the journal Anesthesiology is nearly twice as effective as low frequency in dealing with chronic back and limb pain.

People who have not responded well to traditional spinal cord stimulation might want to investigate a new variation that specifically works on the dorsal root ganglion, a small bundle of nerves connected to every vertebra in the spine. The FDA just gave it the green light earlier this year. These nerves act like traffic lights, controlling what sensations enter the spine, and electric stimulation can switch on the red light for pain. Because the leads are smaller and can be positioned more precisely, research has indicated that the devices are particularly helpful in treating pain that's hard to target with traditional spinal cord stimulation, such as in the groin, foot or lower limbs.

Next up is a not-yet-approved stimulator that delivers "burst stimulation," instead of a constant flow. The theory is that the intermittent pulsing mimics nerve cells, providing better relief. A 2015 study published in the Clinical Journal of Pain found that burst stimulation "was significantly better" than the constant kind, and that nearly two-thirds of patients who weren't helped by standard stimulation responded.

[See: Osteoarthritis and Activity: Walking It Out.]

Implanted pump. The titanium pump, like the stimulator device, is enjoying new life. Implanted pumps deliver medications (including opioids) in a targeted way to the fluid surrounding the spinal cord, which means they can be given at a fraction of the dose received orally. "If you're giving a dose of 300 milligrams of a drug orally, like morphine, you can give 1 milligram of that drug to the spinal fluid and have an approximately equal effect," says Dr. Lance Roy, an assistant professor of anesthesia at Duke University Medical Center. "The tiny doses minimize some of the side effects and really improve quality of life." Implanted pumps are frequently used in people for whom oral medications or injections haven't worked or for whom the side effects were intolerable.

The devices deliver medicine to the spinal cord via a catheter, and are refilled every one to three months at the doctor's office through a needle. Technological advances have made the pumps safer and more convenient; they can now be programmed by remote control to release the proper dose, for example.

Still, pumps are by no means a sure bet. A 2014 review of studies published in the Journal of Pain Research suggested that while they're useful for treating cancer pain, it's hard to draw conclusions about how well they relieve other types, in part because of the lack of randomized trials.

Biacuplasty. One new option for treating chronic pain of the neck or back resulting from herniated or bulging disks is a 30-minute outpatient procedure that uses X-ray guidance and two electrodes to create lesions along the disc nerves. The nerves are thus inactivated and can no longer transmit pain signals to the brain. Research presented at last year's American Academy of Pain Medicine meeting suggested that the procedure, which is less invasive and less risky than the surgical procedures, worked better than so-called "conservative" back pain therapies, which include weight loss, acupuncture and anti-inflammatory drugs.

The procedure is "something that can help with one of the most common disabilities in the Western world: low back pain," says Dr. Paul Christo, an associate professor in the division of pain medicine at Johns Hopkins who is also the host of "Aches and Gains," a five-year-old radio show on Sirius XM about overcoming pain. Biacuplasty coagulates the nerves in the discs, he says, and there's a chance it may even help heal fissures or cracks in degenerated discs. "We just don't know yet, but I think there's great potential there." Biacuplasty is still too new to be covered by most insurers.

[See: 8 Lesser-Known Ways to Ruin Your Joints.]

Drug therapy. Drugs other than opioids have been around to treat pain for years, too; there's a focus now on trying them before moving on to the more problematic painkillers. Anticonvulsants such as Lyrica can lessen neuropathic pain, though doctors aren't sure how. Antidepressants are sometimes prescribed for musculoskeletal pain and diabetic neuropathy; they work by increasing the neurotransmitters serotonin and norepinephrine, which reduce pain.

Botulinum toxin, aka Botox, is also being recruited. It blocks the release of the neurotransmitter acetycholine, forcing muscles to relax. The drug has been approved to treat migraines. A 2013 review of studies found that a single injection could relieve pain and improve function and quality of life in people with arthritis, though the paper noted that the studies were small.

Researchers are also investigating new drugs, one of the most promising being injections of a compound called resiniferatoxin found in a cactus-like Moroccan plant that works by blocking the transmission of pain signals. Essentially, the substance -- 1,000 times hotter than capsaicin, the chemical in hot peppers -- destroys the neurons responsible for inflammatory pain by burning them.

Anti-nerve growth factor modulators, a class of drugs that excites Christo, prevent the protein from binding to its receptor on neurons, thus blocking pain transmission. And cannabinoid receptor agonists -- which, as their name suggests, are a derivative of cannabis -- may have potential, too. These drugs target cannabinoid receptors, which are located throughout the body and play a role in pain.

[See: 10 Seemingly Innocent Symptoms You Shouldn't Ignore.]

Stem cell therapy. In this controversial procedure, doctors take bone marrow from the hip, remove stem cells and inject them into areas plagued by pain. The idea is that the stem cells may turn into new cartilage and tissue. A 2014 international clinical trial found that a single injection into degenerated discs reduced low back pain for at least a year. But "we're still really in the infancy stages with this," cautions NYU Langone's Kim.

Stem cell therapy is often performed in conjunction with another experimental procedure using platelet-rich plasma, or PRP. Blood is drawn and plasma is extracted by spinning the blood in a centrifuge. Concentrated platelets and other nutrients are added in, and the mixture is injected near the pain site. Theoretically, the PRP promotes healing. The treatment has a long (though inconclusive) history of use to treat injured professional athletes.

Some doctors see promise; plenty are skeptical. "There's more evidence to back up acupuncture" than PRP, Kim says. According to the American Academy of Orthopaedic Surgeons, it so far seems most effective for chronic tendonitis of the elbow or Achilles tendon.

One happy customer is Dean Scarpa, 56, a business owner from Voorhees, New Jersey, who suffered from arthritic pain in his knees, then tore his anterior cruciate ligament and meniscus in his right knee skiing. Scarpa says he was told he'd need surgery, but he was disturbed when he read that few skiers get back to their previous levels after an operation. So instead he went to a Philadelphia-area sports medicine doctor, who performed the stem cell procedure over a month. Within three months, Scarpa's knee felt better, and within six months, he could jump on it. He then had the PRP treatment on his left knee. The pain there, too, has gone away. "I knew there was a chance these things might not work" and surgery might become necessary, Scarpa says. So far, it hasn't been.