Opioid alternatives: What options exist and do they work?

The devastating toll the opioid epidemic has taken on America is clear: more than 42,000 people died of a drug overdose related to an illicit opiate or a legally prescribed painkiller in 2016. Having already looked at the scope and scale of the crisis the nation faces, it's time to focus more on what effective steps can be taken to combat the public health emergency that only threatens to grow more expansive and lethal.

Among the first places to look at to stem the tide of opioid overdose deaths and cases of abuse is opioid prescriptions themselves. According to the U.S. Centers for Disease Control and Prevention, opioid prescriptions effectively quadrupled between 1999 and 2014 with no accompanying increase in the pain reported by Americans. The abundance of legal pills flooding the market, homes and communities only increases the chance of misuse and abuse. That's what makes opioid alternatives to pain all the more important to consider.

Finding treatments that can reduce patient exposure to opioids and work just as well at relieving symptoms are the overwhelming objective of many in the health care community. Only time will tell how capable they are at combating the opioid crisis, but alternative treatments hold promise. Here's some more information on a few of those solutions:

Over-the-counter, nonopioid painkillers

Legal opioids like hydrocodone and oxycodone have proliferated in part perhaps because of the apparent misconception they are more effective than over-the-counter, painkilling medications like Ibuprofen and acetaminophen. However, as a recent study found, there isn't a big gap in effectiveness of over-the-counter painkillers compared to prescription opioids in treating pain.

Research published in the Journal of the American Medical Association tested how ER patients responded to various doses of opioid analgesics and opioid-free painkilling options to see if any statistically significant insight into effectiveness of one type of drug over the other could be produced. The study reasoned the experiment was important because, despite the high rate of opioid prescriptions, there seemed to be a lack of evidence demonstrating these medications were actually better at treating acute pain. The patient population - 411 emergency room visitors - was randomly given one of four dose options: Ibuprofen and acetaminophen; oxycodone and acetaminophen; hydrocodone and acetaminophen; or codeine and acetaminophen.

opioid alternatives

Alternative treatments to opioids are being developed in response to the drug crisis in America.

The results were illuminating. Operating from a baseline pain score of 8.7 on a 10-point scale, researchers asked participants about their level of pain two hours after taking the medication. The mean pain score was reduced by 4.3 in the Ibuprofen/acetaminophen group, by 4.4 in the oxycodone/acetaminophen cohort, by 3.5 in the hydrocodone/acetaminophen group and by 3.9 in the patients given codeine/acetaminophen. Essentially, no single combination of opioids and OTC painkillers proved to be more effective than the other: There was no statistically significant or clinically important difference the researchers could measure. This is notable because of the near automatic reaction many physicians have developed to favor opioid medications over other available options. 

"Some docs will reflexively give an opioid to anyone with a fracture," Dr. Andrew K. Chang, lead author and professor of emergency medicine at Albany Medical College, told The New York Times. "But if we can give the nonopioid and show the patient that it works, we can help with this ongoing opioid problem."

Integrated pain management programs

In some cases, the best approach to treating pain is not an all-out reliance on prescription medications, but taking a comprehensive look at all the factors affecting pain and how they can be managed from a personal standpoint. This is one emerging type of opioid alternative that has gained traction in communities across the country, like in Colorado, where NPR recently reported on a new pain management program offered to state residents by the not-for-profit, health plan provider Kaiser Permanente.

The eight-week course is available to high-risk opioid patients, and connects them to an integrated service that helps them manage the totality of pain and the ever-present danger of opioid addiction. For example, not only do participants interact with a clinical pharmacy specialist who can educate them on the science behind addiction and opioids, but also utilize other personnel like a clinical psychologist, a doctor, a physical therapist and a nurse. The centralized approach can help streamline patient care and lead to greater connection and collaboration among professionals. The integrated team can craft personal plans that either help patients replace opioids with exercise, mediation and acupuncture to manage pain, or find them a suitable medication-assisted treatment with alternative drugs.

"Integrated services can help patients manage the totality of pain."

"We've seen great success with these models that are integrating complementary therapy, physical therapy, behavioral health and medical care," Dr. Kelly Pfeifer, who's studied Kaiser's program in Colorado and is the director of high-value care at the California Health Care Foundation, told NPR. "It works so much better when the patients have access to these complementary therapies. And it works even better when those complementary therapies are part of an integrated team."

Nonaddictive opioids

Advances in pharmaceutics and biotechnology have produced a whole new range of drugs that can treat diseases with highly engineered treatments. One recent breakthrough could light the path forward to developing a nonaddictive opioid that may help alleviate the toll of the current crisis by introducing a safer drug to the market. A team of researchers from the University of North Carolina at Chapel Hill published a paper in the journal Cell that discussed findings related to the kappa opioid receptor (KOP), which could hold the key to potentially making opioids and overdoses less deadly.

Opioid receptors, as explained by WIRED magazine, are proteins that opioid drugs bond to in the body. When in an active state, receptors embed themselves in the walls of the cells found in the brain and peripheral nervous system, from where they can act as "gatekeepers" and unlock chemical painkilling properties — as well as addictive and deadly reactions. The KOP is just one of four opioid receptors (along with mu, delta and nociceptin), and as WIRED mentioned, it has been the basis for a growing amount of research theorizing how the receptor could trigger therapeutic pathways that lead to pain alleviation without the negative side effects.

Until the UNC-Chapel Hill research, however, the shape of the KOP wasn't precisely defined. That was an obstacle to nonaddictive opioids because knowing the KOP shape was critical to constructing a drug that would bind to it and not the mu receptor, which activates those lethal pathways.

"The problem has been that we don't have any drugs that are super selective for either pathway," pharmacologist Bryan Roth, a physician researcher at the school told WIRED. But now that their study has presented a clearer picture of the KOP shape and function in a drug-activated state, there's hope yet that even more breakthroughs will be made in formulating a less dangerous type of opioid that could be used as another alternative.