Co-Occurring Disorders and Your Child
If your child has been diagnosed with co-occurring disorders, it can be helpful to stay vigilant, especially during this time of social distancing.
Whether your child has struggled with opioid dependence or other substance use issues previously, or whether you’re just concerned about the current opioid crisis, there’s good reason to want your son or daughter’s pain to be managed – if possible – by something other than prescription opioid pills. Eventually, your child might have an orthopedic injury or need a tooth pulled at the dentist, so what happens then?
While opioid medications may be effective for treating pain in the short-term, they have an extremely high propensity for addiction and do nothing to address the underlying cause of the pain.
The good news is that there are many alternatives to opioids that can help alleviate your son or daughter’s pain. Below, we’ve helped to spell them out for you and have provided guidance on how to ask your doctor about these alternatives.
Often, especially in the case of short-term pain management for a dental procedure or broken bone, there are alternative medications and treatments available. It’s unfortunate that in many cases opioid prescriptions are still a common practice, but with your advocacy on behalf of your child, you can discuss other options with your child’s doctor to avoid opioids and other medications that may be habit-forming entirely and still manage your child’s pain.
Ibuprofen or Naproxen – These are over-the-counter, nonsteroidal anti-inflammatory drugs (NSAIDs) usually used to treat headaches, muscle aches, toothaches and cramps. Their most common side effect tends to be stomach discomfort. Naproxen lasts longer than Ibuprofen and thus might be more appropriate for chronic pain conditions.
Celecoxib or Meloxicam – These are power anti-inflammatory agents that belong to the same family as medications like Ibuprofen or Naproxen. The main difference is these are much softer on your stomach and cause less gastrointestinal side effects.
Flector & Lidoderm Patches – Topical medications are quite effective in many cases when the pain is coming from the muscles or other superficial areas. These are sometimes preferable to oral medications in that the drug is going directly to the area(s) of need with a bare minimum reaching the blood supply. The patches are placed directly over the area(s) of pain and are designed to work around the clock – they are kept on for 12 hours at a time, and then taken off for 12 hours. Ideally, these patches are designed to continue working even when during 12 hours when they are off.
Voltaren Gel – Similar to the patches, this topical medication is applied to the area(s) of need with very little reaching the blood supply. The main difference is that the gel needs to be re-applied several times throughout the day. This may be preferable to a patch if one cannot have a patch on or in hot weather when a patch simply will not stick.
Tizanidine – This is an old medication that was traditionally used for Cerebral Palsy. It is considered a muscle relaxer and has a more minimal side effect profile, and therefore is preferable to other more commonly-known muscle relaxers. Tizanidine does not enhance the euphoria of pain medication, and is not addictive.
Gabapentin – This drug is considered to be an “anti-seizure medication” however it is most commonly used to treat neuropathic pain – it is most commonly used for diabetic foot pain. It is widely prescribed however at higher doses the side effects tend to increase in prevelanc (i.e. sleepiness, blurred vision, water retention, and difficulty concentrating). There no risk of addiction; however, it should not be stopped abruptly.
Cymbalta – This is an antidepressant that has been found to treat low back pain and fibromyalgia.
In some instances, pain can be overwhelming — so much so that the above medications simply will not cut it. To say that someone who just had their wisdom teeth pulled or suffered a broken arm should rely on something like Ibuprofen is unrealistic. What to do in situations such as these is covered in Does My Child Need Opioids to Cope with Severe and Acute Pain?
Chronic pain is defined by the CDC generally as pain that lasts more than three months. It’s a complex issue to manage successfully, but especially so in the case of someone you’re concerned about developing an addiction, or someone in recovery. The CDC actually recommends against opioids as the solution for chronic pain management, as they say the risks from opioids greatly outweigh the benefits for most people. Fortunately, there are several other methods to help manage these chronic issues that you and your child can discuss with a physician.
Physical Therapy (PT) – This is considered by most to be the “first-line” treatment for pain. There is an abundance of evidence proving the efficacy of PT to treat most types of pain, especially low back pain, hip or knee osteoarthritis, or fibromyalgia. However, the maximum improvement of PT is typically reached by 8 to 12 weeks, meaning that pain persisting beyond this time is not likely to improve unless other measures are explored.
Chiropractic – Similar to PT, chiropractic is considered a first-line treatment that has lasted the test of time. Also like PT, the maximum effects are typically reached within a few months and may need to be supplemented with other types of treatment.
Epidural Injections – This is the main tool for pain doctors across the world for treating back and/or neck pain. The basic concept is very similar to the “epidural” given to women at childbirth; however, the goal is not to cause numbness. Your doctor will use a ‘cocktail’ consisting of a local anesthesia to lessen the pain, cortisone to decrease inflammation and saline to wash out inflammatory molecules in the area.
Facet Injections – The small joints that you feel when you crack your neck or back are called facets. And like any joint in the body, arthritis can set in and make it painful. Epidural injections will not work for this type of pain, as they lie outside the spine (whereas an epidural treats pain on the inside). Facet injections are similar to a cortisone injection for knee pain – a small amount of an anti-inflammatory is injected into one or several of these small joints to eliminate pain. Some doctors prefer to treat pain coming from these joints using radiofrequency ablation (see below). Before an ablation can be performed, your doctor will perform a nerve block to locate which facet is causing the pain first.
Nerve Blocks – This procedure can be used to diagnose as well as treat pain coming from a nerve. The only test that can diagnose nerve-related issues is called an electromyography (EMG); however, it is not always reliable and often cannot relay what nerve or nerves are causing the pain. A nerve block is where your doctor injects a local anesthetic, sometimes with a small of amount of cortisone, to ‘turn off’ the nerve suspected to be causing the pain. If the pain decreases after the injection, this will tell your doctor where the pain is coming from. In some cases, a nerve block can last several months. In cases where the effects only last a few hours, other treatments can be implemented (i.e. radiofrequency ablation) to block the pain for longer periods of time.
Botox Injections – Also known as botulinum toxin, most people know botox for its ability to eliminate wrinkles and help people look younger. What many do not know is botox can be used to treat headaches and muscle-related pain. Typically, they are covered by insurance when used in this fashion.
Radiofrequency Ablation (RFA) – This is a commonly performed procedure, particularly for chronic pain in the lower-back and arthritic joints, used to ‘turn off’ painful nerves using special needles called a cannula. The tip of this needle will convert radio waves into energy – when a nerve is caught in the path of this energy, it will stun the nerve and prevent it from sending pain signals to the brain. For better or worse, the nerve will grow back in 12 to 18 months — meaning this procedure is reversible.
Genicular Nerve Ablation – This is a type of RFA (see above) that is used to treat knee pain. Traditionally, if knee pain does not respond to injections, the only alternative is surgery. By targeting the nerves of the knee that transmit pain signals (genicular nerves), your doctor can decrease or even eliminate pain without surgery.
Ketamine Infusions – When used correctly, ketamine infusions can be quite successful for chronic pain issues – like any medical treatment, however, they are not always 100% successful. Ketamine infusions can be done either as an inpatient or as an outpatient procedure. In the former, you will be admitted to the hospital for several days and administered high doses of ketamine. In the later, you will receive lower doses of ketamine in your doctor’s office for several hours at a time. Both options are very time intensive and there no evidence to suggest that one is more effective than the other. It’s important to note that many insurance companies do not cover them and medical practices that do administer them charge cash, which unfortunately puts them out of reach for many people.
Platelet Rich Plasma (PRP) – These treatments were originally invented by dentists and oromaxillofacial surgeons to help with healing after extensive dental and jaw reconstructive procedures. Over time, doctors started to apply the concept to joints, ligaments and tendons to help injuries heal without surgery. The idea is simple – isolate and concentrate the portion of the blood that promotes healing (platelets) then inject it into an area to accelerate healing. Unfortunately, no insurance company covers PRP despite the fact that there is quite a bit of evidence to show it is extremely effective at treating certain injuries. Because it is a cash procedure, there is no approval process so some doctors will use it on whatever the patient is willing to let them. While PRP is very effective, it cannot treat everything – evidence suggests it should be used on pain related to tennis elbow, golfer’s elbow, tendonitis, and certain types of soft tissue injuries or tears.
Sometimes, depending on your child’s pain situation, medication and other therapies alone will not work for their needs long-term. In that case, you may want to discuss other options with your child’s physician to see if minimally-invasive surgical procedures might be a good option and solution for your child’s pain.
Spinal Cord Stimulation (SCS) – This therapy is quite similar to a pacemaker for the heart — but instead of a wire going to the heart to make it beat correctly, the wire goes to the spine to control certain signals to relieve pain. The wire is placed in the same way as an epidural for childbirth, except there is no medication going through it to make you feel numb. The wire will give off small electrical impulses which are meant to block certain types of pain. SCS has been used for over 50 years. It can be used for people who do not want to get spine surgery or are not candidates for it. In some cases, a person may get surgery and still have pain – a stimulator is very effective in these instances as well.
Dorsal Root Ganglion (DRG) Stimulation – This is a cutting-edge therapy that is very similar to SCS. The only difference is the wire is placed over a small bundle of cells called the dorsal root ganglion (DRG), which sits right next to your spinal cord. DRG stimulation has been shown to be extremely effective for treating small, focal areas of pain like a neuropathy in the feet or conditions like Complex Regional Pain Syndrome (CRPS).
Interspinous Spacers for Spinal Stenosis – Traditionally, the only way to treat spinal stenosis was for a surgeon to open up certain areas of the spine to create room and relieve pressure off the spinal cord. There is no question that surgery is effective; however, the recovery can be difficult and long. Some people may not want surgery or may not be a candidate due to their age or other health conditions. Interspinous spacers are a minimally invasive way of creating just enough space to relieve pressure off the spinal cord and decrease pain. The spine will remain exactly as is and there is virtually no risk of causing any scar tissue on the spinal cord itself. For those who do not want surgery or cannot get it, this is an excellent option. Currently in the United States, there is a platform called the Superion Interspinous Spacer which has been shown to treat low back and leg pain from spinal stenosis with evidence showing it efficacy out to 5-years. Medicare also covers it.
Microdiscectomy – When a spinal disc bulges or herniates, it may put pressure on the spine or a nearby nerve. Epidural injections are a good early step to relieve the inflammation and swelling in the area caused by the disc. In some instances, the damage may be too great or the disc is simply causing too much pressure and needs to be corrected. A microdiscectomy is a minimally invasive means of reducing the size of the disc and relieving pressure off the spine and/or nerves. Traditionally, surgeons would need to make large incisions to be able to see the spine with the naked area. A microdiscectomy is a newer technique whereby the surgeon will make a small “buttonhole” incision and use special instruments to accomplish the same thing. In some instances, the surgeon may elect to use a small scope called an endoscope that is no wider than a pencil to see the spine up close and allow him or her to be even more precise. The recovery from a microdiscectomy is much shorter and typically preferred over an open surgery.
Kyphoplasty – Fractures of the bones of the spine are called vertebral compression fractures. They are extremely painful and can be quite common in person diagnosed with weak bones (such as osteoporosis or osteopenia). A kyphoplasty is a minimally invasive procedure whereby your physician will place one or two small tubes the size of small straw through your skin and into the fractured bone. Then a small balloon is threaded down through the straw and into the bone. Like a jack being used to lift up a car, the balloon is then inflated to fix the fracture and decompress the bones. A small amount of medication with the consistency of plaster is injected inside the bone to seal it and strengthen it.
Intrathecal Pump – In some cases, the damage to the spine may be too great, or the pain may just not respond to the treatments described above. In those instances, the only thing that may actually be effective is medication. A pump is a way delivering miniscule amounts of certain medications directly to the spinal cord to relieve pain directly at the source. Once such medication is Ziconotide (Prialt) — a powerful non-narcotic pain reliever, isolated from the toxin of a type of sea snail. With Prialt, there is no risk of addiction or overdose.
As a reminder, be sure your child carries an identification card or bracelet if using medication-assisted treatment for opioid use disorder and shares his or her history and current medications with all providers.
Many thanks to Dr. Corey Hunter, CEO of the Ainsworth Institute of Pain Management, for this post. Please note that the Partnership for Drug-Free Kids does not endorse any of these procedures or medications. We always advise that you discuss these alternatives with your physician.
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