As the scourge of opioid overdose continues to claim more than 100 U.S. lives a day, Cleveland Clinic’s Neurological Institute is addressing opioid dependence and addiction in an increasingly multidisciplinary fashion — and with strategies focused on prevention, treatment/weaning or a combination of the two. Here are three snapshots of how Neurological Institute clinicians are contending with the crisis in distinctive and meaningful ways.
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The treatment of chronic back pain too often misses the mark, says Edward Benzel, MD, Cleveland Clinic’s Emeritus Chairman of Neurosurgery. As a veteran spine surgeon, he has been witness to an exponential rise in the number of patients suffering from chronic back pain who have been inappropriately treated with opioid medications, injections and spinal surgeries that end up resulting in drug dependence or addiction and even worse pain.
“Most people with chronic back pain have a biopsychosocial disorder rather than a physical disorder that is amenable to a simple medical intervention,” says Dr. Benzel. “They don’t need ‘painkillers,’ injections or surgery. In fact, they are best managed by a completely different approach to the restoration of function and the resumption of a functional life and lifestyle.”
In response, Cleveland Clinic has introduced Back on TREK (for Transforming, Restoring and Empowering patients while providing Knowledge), a collaborative program that draws from the following Neurological Institute subspecialty areas:
The program’s interdisciplinary approach, detailed in a previous Consult QD post, is aimed at enhancing and restoring function of patients living with chronic back pain while avoiding the premature use of imaging, addictive medications, injections and spine surgeries.
According to Dr. Benzel, who serves as Back on TREK’s director, the program entails a dramatic shift from patients passively receiving a medical treatment to being empowered to improve their health, function and life more broadly. Physical therapists and clinical psychologists collectively help patients restore function, manage psychosocial issues, and eliminate or drastically reduce opioid use.
Dr. Benzel acknowledges that a challenge with the model is that public and private reimbursement algorithms heavily favor surgical interventions and medications over physical and behavioral therapy. He expects that this incongruity will rebalance, however, as hospitals and payers increasingly recognize the importance of avoiding unnecessary surgery and opioid reliance and focus on programs that best improve patient outcomes.
Cleveland Clinic’s Center for Behavioral Health operates the Alcohol and Drug Recovery Center, a center of excellence and fully accredited program for treating chemical dependence. Short-term inpatient treatment is available for patients requiring close medical supervision while undergoing detoxification, as are longer intensive outpatient programs to help patients develop relapse-prevention tools and maintain gains.
Yet those long-standing programs are just the beginning of the Center for Behavioral Health’s initiatives as it increasingly aims efforts at the medical community and the public at large to fight opioid misuse where it’s most likely to be found. Its staff have long been involved in the U.S. Attorney’s Northeast Ohio Heroin and Opioid Task Force, which was honored with the prestigious U.S. Attorney General’s Award in 2016 (see previous story). Task force strategies include making naloxone more readily available, educating providers about appropriate opioid prescribing, and enhancing law enforcement.
Center for Behavioral Health psychiatrist David Streem, MD, points to other efforts, such as an innovative collaboration with Cleveland Clinic cardiac surgeons. Traditionally, many cardiac surgeons have refused to offer lifesaving valve replacement to IV drug abusers who develop infective endocarditis (a common complication of such abuse) because of the likelihood of relapse with continued drug abuse. But Dr. Streem advocates for a more compassionate approach.
“Today’s addicts are often young parents with small children,” he says. “Many people would benefit if they were given another chance.”
Center for Behavioral Health psychiatrists met with Cleveland Clinic cardiac surgeons and developed a novel plan: to offer surgery to drug addicts if they sign an agreement to undergo opioid addiction treatment. Dr. Streem explains that because patients needing valve replacement require hospitalization for IV antibiotic therapy before surgery, this offers a perfect opportunity to provide supervised addiction counseling and medication-assisted addiction treatment. After surgery, the patient enters intensive comprehensive drug rehabilitation.
Center psychiatrists are now reaching out to other Cleveland Clinic departments that frequently treat patients who might be prescribed opioids or are already addicted. They are developing best-practice guidelines with anesthesiologists and surgeons for managing pain, and they are making their drug treatment services better known to emergency physicians and obstetricians, who are often the first point of contact for addicts.
“The role for opioids is temporary use against acute pain,” says Dr. Jimenez, a psychiatrist who also directs the Chronic Pain Section in the Center for Neurological Restoration. “Long-term use leads to hypersensitivity to pain, resulting in a vicious cycle of dependence and ever-higher dosing.”
The CPRP — which is targeted to patients with conditions ranging from functional somatic/central sensitization concerns to spinal disorders, back pain, failed back-surgery syndrome and more — is a multidisciplinary program that involves three to four full-time weeks of intensive physical and occupational therapy, individual and group counseling, relaxation strategies and pharmacotherapy. Roughly half its patients enter its chemical education track to more intensively address opioid dependence issues.
Although many patients have previously tried many of these therapies, the program’s strategy of tackling the problem on multiple fronts in a coordinated, customized manner is critical to its success, says Dr. Jimenez.
As detailed in a previous story, the program was one of the first of its kind in the U.S. and has helped over 6,000 people since its launch in 1979. An outcomes study published in Pain in 2017 reports that the program is highly successful in reducing opioid use as well as improving function, pain and mood.
Dr. Jimenez emphasizes that success is contingent on strongly motivated patients willing to devote up to a month for full-time efforts to live effectively with a chronic pain syndrome and to conquer opioid dependence. “Success also depends on the backing of an institution that can provide the variety of resources needed to be effective,” he adds. “We’re fortunate that Cleveland Clinic is such a place.”