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  • CDC Says Nondrug Approaches 'Preferred' to Treat Chronic Pain; APTA Adds its Support

    The US Centers for Disease Control and Prevention's (CDC's) draft clinical guidelines on the use of opioids for chronic pain make it clear: nondrug approaches such as physical therapy are the "preferred" treatment path for chronic pain.

    APTA couldn't agree more.

    This week, APTA submitted comments to a new CDC document aimed at primary providers who may prescribe opioids to treat chronic pain. The guidelines attempt to rein in growing rates of opioid use disorder and opioid overdose, and to help reduce the prevalence of opioid prescriptions, which topped 259 million in 2012—"enough for every adult in the United States to have a bottle of pills," according to the CDC.

    The guidelines were developed after expert review of evidence around not only the effectiveness of opioids (and their dangers), but also the ways in which nondrug approaches can be used in treatment. After evaluating the evidence, the CDC drafted recommendations around determining when to initiate or continue opioids for chronic pain, as well as guidelines for drug selection and dosage, and risk assessment.

    Its first recommendation: "Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain."

    "Based on contextual evidence, many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, complementary and alternative therapies (e.g., manipulation, massage, and acupuncture), psychological therapies such as CBT, and certain interventional procedures can ameliorate chronic pain," the draft states. "In particular, there is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip … or knee … osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2–6 months."

    In its comments to the draft, APTA applauds the recommendations, stating that approaches such as physical therapy "have been underutilized, and, therefore, can serve as a primary strategy to reducing prescription pain medication abuse and improving the lives of individuals with chronic pain."

    APTA's comments also note that referral to exercised-based interventions "is essential prior to the initiation of opioid-based therapy," and that exercise interventions "have the potential to improve health outcomes, reduce costs, and decrease the risks associated with opioid prescriptions."

    The association goes on to recommend that the CDC provide clear guidance on the patient populations that would benefit from nondrug approaches, and that more extensive patient education resources should be developed on the benefits of exercise-based interventions over opioid prescriptions. This education needs to be aimed at both the public and primary care providers, ATPA writes.

    APTA also added its support to CDC recommendations around the use of multidisciplinary approaches to management of chronic pain, such as a combination of physical therapy and cognitive-based interventions. The problem, the association points out, is that although supported by evidence, the approaches "have been challenged by reimbursement policies." APTA recommends that the use of multimodal approaches to treat chronic pain be part of a broader effort to change payment policies in ways that make them more amenable to nondrug approaches to chronic pain.

    The CDC guidelines—and APTA's comments—come at a time when the fight against opioid abuse and heroin use has gained attention at a national level. The issue was a part of President Barack Obama's final State of the Union address on January 12, and the epidemic is the subject of a White House initiative that includes APTA and other health care and corporate partners. At the state level, West Virginia—one of the states hardest hit by the opioid abuse problem—has announced the formation of a new House committee on substance abuse. That committee includes Rep Mick Bates, PT.


    • Great, but will be much more effective and useful if patients have direct access to PT from Medicare to get treatment when needed before turning to pain meds.. Time to stop playing the referral game and treat the pt right from the beginning.

      Posted by Dan PT on 1/20/2016 5:18 PM

    • I could not agree more with this article! Wonderful to hear that PT has the potential to gain it's due place in managing chronic pain. I could also not agree more with the statement...The problem is that although supported by evidence, the approaches "have been challenged by reimbursement policies." If payors will not pay for PT to manage chronic pain with non-pharmaceutical approaches, they leave PCP's and MDs little choice on how to help their patients in chronic pain. We need to have a strong stance on attaining reimbursement for PT to help these patients. I hope the APTA will use this opportunity to press for wider reimbursement for PT services in this much needed area.

      Posted by Tobin Forbus on 1/20/2016 5:53 PM

    • Even though exercise is certainly essential for regaining strength, ROM and function it is often times not helpful and often times harmful(increases their pain) for patients with chronic pain as evidenced by reports from my patients. I see frequently in PT statements published that the PT does not focus on pain, instead function. Using just ex. and not incorporating modalities like manual therapies which PT's are using less often and when they do it is often times painful and aggressive and counter to helping pain. The economics of it drives much of this since we can see more pts. in a gym than one-on-one hands on work. We need to rethink our approach to chronic pain.

      Posted by Richard Fowler, PT on 1/20/2016 6:25 PM

    • I applaud the efforts of the APTA. What bothers me is the negative comments made by pain management's specialists on their own president, regarding the change in treatment approach.

      Posted by Michelle Guevin on 1/20/2016 8:21 PM

    • We have been saying this for long time. Autonomus Physical therapist will contribute more to the goal of CDC.

      Posted by Mubarak Ali Mirjat on 1/21/2016 6:34 AM

    • We cannot cure all pain, but some wise advice can do wonders. Activity management, such as decreasing stair climbing for "older" folks with knee OA, less prolonged sitting and appropriate chairs for back and neck pain, footwear, exercise and fitness adaptations, can play a major part in pain control. People have been told to take their meds before pain starts. This is ridiculous and directly leads to addictions and overuse. Changing posture, exercise and activity can prevent a lot of pain.

      Posted by Olivia Howard on 1/22/2016 5:29 PM

    • A large percentage of these chronic pain patients have significant underlying emotional and pathological thought processes contributing to their pain. We as a profession are not trained enough to apply good evidence based cognitive behavioral psychology. I recommend getting to know a good psychotherapist in your area who specializes in pain management and establish a relationship as a good referral source. Any type of manual therapy is contra-indicated, this passive intervention will do nothing except create more dependency. Movement and psychological intervention is the key. There is no evidence to suggest autonomy and direct access would significantly improve these patients outcomes. We as clinicians need to know our limitations

      Posted by J Hendricks PT on 1/22/2016 10:52 PM

    • The US Centers for Disease Control and Prevention's (CDC's) draft clinical guidelines on the use of opioids for chronic pain is supportive of physical therapy services as one of the primary treatment paths for managing chronic pain issues. Significant federal funding is now needed to develop our workforce so we can have equal access to opportunities to develop infrastructure that supports autonomous PT practitioners who are knowledgeable and skilled in treating the whole person, including those with cognitive and mental health issues. I encourage all who are interested to visit the AGPT's new Cognitive and Mental SIG webpage for more information. We are a welcoming and collaborative group of volunteers who are passionate about this area of practice, and we are working hard to learn from each other and generously share what we know. Come join us @ www.geriatricspt.org!!

      Posted by Dr. Lise McCarthy, PT, DPT, GCS on 3/18/2016 12:01 PM

    • Physical therapy may work but does the patient who has sever pain do until the therapy can work its wonder? Must they just suffer in silence?

      Posted by Helen Welter, RN on 5/4/2016 12:05 AM

    • @ Helen Welter: Of course a patient must not suffer. CDC allows that certain situations call for opioids, and even ones where opioids COULD be avoided that the "start low, go slow" approach is best. When opioid prescription rates have gone through the roof in just the past 15 years of human life, let's not suggest that reducing the amount of opioid prescriptions and directing people to healthier alternatives is akin to making people suffer. The risks posed by opioids are very real. Health care providers should be gravely concerned about the suffering in silence patients will do because of the harmful effects of opioids.

      Posted by Mick Frank on 5/6/2016 2:42 PM

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