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  • Opioid Prescription Study Sparks Talk of Nondrug Approaches to Chronic Pain

    A new study on access to prescription opioids has garnered media attention—and triggered more discussion about the need for physicians to more carefully consider other treatments for chronic pain, including physical therapy.

    The study, covered by Reuters, The Boston Globe, and other media outlets, found that more than 90% of individuals who survived a prescription drug overdose were able to get another prescription for the same drug after the overdose. And it would seem that for the most part, it wasn't that hard to do—70% of the people who obtained the postoverdose prescription got it from the same physician who prescribed it earlier.

    Quoted in the Reuters article, lead study author Marc Larochelle, MD, said that a possible explanation for the "surprising and concerning" results is that "providers are not aware that their patients experienced an overdose when making the decision to continue prescribing opioids."

    The Boston Globe characterized the study as one that suggests "major gaps in communication, education, and oversight."

    Closing those gaps will require physicians to pay careful attention to signs of opioid abuse among their patients and to consider treatments other than opioids for chronic pain, according to Larochelle.

    "In addition to any potential opioid use disorder, we need to communicate alternative options for treatment of chronic pain, and all modalities should be considered, including nonopioid medications, physical therapy, and complementary and alternative treatments," Larochelle told Reuters.

    Jessica Gregg, MD, who wrote an editorial that accompanies the study, echoed Larochelle's points, telling Reuters that "in a perfect world, a physician would be able to work with a team that might include physical therapists and/or occupational therapists, alcohol and drug counselors," and others with related expertise.

    In the Globe article, Gregg says that while effective, treatments that rely less heavily on opioids are "slow fixes" that the current health care system isn't "particularly well set up" to accommodate. She characterizes physical therapy and emotional health treatment as "things that will help, but not quickly."

    The study, published in the Annals of Internal Medicine (abstract only available for free), surfaced in the media not long after the US Centers for Disease Control and Prevention (CDC) issued a report stating that drug and opioid overdose deaths in the US rose dramatically in 2014, to 14.7 per 100,000 persons. That's an increase of 6.5% over the 2013 rate, part of a trend that has amounted to 137% increase in overdose death rates from all drugs since 2000. Death rates from opioid pain relievers and heroin increased by 200% during that same time.

    APTA has taken an active role in bringing the physical therapy perspective to the fight against prescription drug abuse and heroin use, and is currently participating in a public-private White House initiative to combat the problem. In addition to APTA, initiative participants include the American Medical Association, the American Academy of Family Physicians, the American Nurses Association, the American Public Health Association, the American Academy of Hospice and Palliative Medicine, and the American College of Osteopathic Surgeons.

    Comments

    • We see "drug seekers" all day long in an ER. Most have no insurance. Even most of those WITH insurance cannot afford the continued amount of physical therapy needed. Other avenues of pain control such as injections, are also too costly as they first require a visit to a specialty MD(have you priced their office visit cost?) who generally requires further testing such as an MRI(thousands of dollars). I am a nurse in a hospital wher the offered insurance covers a maximum of 80%, after you reach your deductable of $3000-5000. That is after paying well over $200to $400 a month for THAT crappy coverage.So you see how Americans can get hooked on drugs, even if it is not their first choice, either! Most Americans do not have the EXTRA $1000, or more, a month for physical therapy.

      Posted by Penny on 1/5/2016 8:57 AM

    • Our profession must do better at assessing the movement habits that lead to "chronic" back pain. I see all of my back patients at least once in their home and work environments to thoroughly assess and correct these habits. These are unique and relate to the individual's environment. These habits are a stronger influence in the individual's chronic pain, than any treatment we can do in the clinic.

      Posted by Marilyn Miller von Foerster PT on 1/6/2016 5:25 PM

    • I particularly like way that this article characterizes "slow fixes" that the current health care system isn't "particularly well set up" to accommodate. She characterizes physical therapy and emotional health treatment as "things that will help, but not quickly." I would say that sometimes PT can be a quick fix but how did we every get pinned in to trying to address chronic problems with a 2 times/week for 4 week referral? It would be the same as giving a diabetic (chronic disease) insulin for 4 weeks and telling the patient to return in 6 months to see how the insulin worked! Chronic disease (including chronic pain) requires "management." I see many chronic pain patients who do quite well with being seen every 2-4 weeks--sometimes more frequently than every 2 weeks and sometimes less frequently than every 4 weeks. This is not "maintenance" (another stupid term introduced in to the PT lexicon). Many of these people have had surgical procedures, injections, etc for years and have done much better with intermittent tweaking to address symptoms as they arise. I hope this can be part of the new PT and new chronic pain model. 12-24 PT visits/year that manages the problem for a whole year is a lot less expensive than any other intervention available.

      Posted by Herbert Silver on 1/6/2016 6:23 PM

    • I think it is important for physicians to understand the changes at the synapse that occur with chronic opioid use. I learned about this by reading David Butler's "The Sensitized Nervous System". He talks about how over time, opioid inhibiting neurons begin to affect the synapse. He is no doubt more accurate than I am in describing this phenomenon. It would be very wise for the CDC to fund studies that help find measures for about how long a human can use opioids and still benefit from them. Disclaimer- These are my opinions and I am not acting as a representative of my employer in sharing this feedback. I have to say this, because my employer is revealed by my email.

      Posted by Lori on 1/6/2016 8:22 PM

    • It is much easier and very often more profitable to the system to just prescribe what the patient orders from the menu. The AMA calls this playing recording secretary. This all too often condones and promotes the ongoing illness behavior instead of dealing with it, or treating it. I believe the emphasis on high satisfaction scores is a big reason for this type of discretionary and sometimes harmful care, and is a big reason why costs for care in the USA are the highest in the world without better outcomes to show for it.

      Posted by Ed Scott PT, DPT, OCS on 1/7/2016 5:25 AM

    • Kudos to the APTA for getting involved in helping combat this fatal epidemic! All physicians have taken an oath to care for people and it is about time they take responsibility for monitoring prescriptions they write out freely!

      Posted by Susan Dias on 1/7/2016 9:56 AM

    • This study is long overdue - the current overuse and abuse of opioids is appalling! It is time for prescribing physicians to take some responsibility for creating this epidemic, and stop the over-prescription of these drugs. And it is time for the physical therapy profession to speak out against the over-use of opioids and promote PT as a safer and perhaps more effective approach to treating pain.

      Posted by Tom Nolan Jr. on 1/7/2016 11:58 AM

    • The rise of deductibles, copays and coinsurances has made physical therapy inaccessible for many, and the hurdles of gate keepers and paperwork a patient must endure to access our services is a persistent barrier for patients. Our current medical paradigm fails to see value in effective, non-invasive and preventative treatments like those utilized by a doctor of physical therapy. We have a plethora of evidence-based medicine around physical therapy regarding injuries and chronic disease. Twenty years ago the lack of evidence may have been an issue. Today there is a plethora of evidence. The only conclusion one can come to is that by limiting access through the burden of paperwork and finances it scares patients away from accessing a physical therapist and keeps profits in the pockets of government and private insurers. The pharmaceutical giants gain as well as people turn to drugs for a quick fix. This is not the type of health care system I want to work in or that I desire for my friends and family.

      Posted by Joe on 1/7/2016 6:47 PM

    • Thank you and well stated Herbert Silver! 👍🏻

      Posted by Sheryl Poremba on 1/7/2016 7:10 PM

    • What I see in my hospital is a monolithic pharmacological approach to pain. A system where the first words out of the clinician’s mouth are, “How would you rate your pain today?” repeated ad infinitum, lends the wrong/negative emphasis to the start of treatment. What middle aged patient couldn’t find a pain to medicate? Alternatively, “Any change to report after your last treatment?” is a neutral statement, geared to collect subjective information without putting words in the patients mouth. In conclusion my pet conspiracy theory: JCAHO is in bed with Big Pharma.

      Posted by Rod on 1/8/2016 10:03 PM

    • This is a tricky nut to crack b/c the recovery is so slow. We have to split hairs to demonstrate increases and gains, improvement with functional activity testing (5x Sit To Stand, Timed Get Up And Go, 5x Box Lift, 1 Min Single Leg Balance, 2 Min Walk Test) to counter the pt's feeling of no improvement with self reporting questionnaires or self reporting ADL tolerance questions. Also there is the fear of the pt, who was treated as an out-pt orthopedic pt instead of a pt with chronic pain, who states "I have had PT and I hate it!" Lastly there is a huge mind game to chronic pain physical rehabilitation in PT with having the pt trust the therapist, become comfortable in their own skin again with normal movement patterns and exercise. Finally there is the pt realization they are not crazy and their pain is caused from chronic bracing, guarding, scar tissue lock down, and physiological changes from the muscles down to nn and hormone sensitivity. This population is really challenging requiring more of a coaching, counseling, information based approach than just straight ther ex to moderate fatigue like post-op approaches. Having the MD, NP, psych on site helps us here to develop a relationship with the pt here at Pain consultants of East TN, but it is still a complicated pt group to progress as they transition off of the medications.

      Posted by Thaddeus MAckiewicz, DPT, CSCS on 1/21/2016 2:25 PM

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