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  • CDC: Physical Therapy, Other Non-Drug, Non-Opioid Approaches Should be First-Line Treatment for Chronic Pain

    In its final version of guidelines for prescribing opioids for chronic pain, the US Centers for Disease Control and Prevention (CDC) minces no words about the importance of physical therapy and other nondrug/nonopioid approaches, and delivers a clear message that physical therapists (PTs) and physical therapist assistants (PTAs) have known for some time: there are better, safer ways to treat chronic pain than the use of opioids.

    Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain," the CDC states in its first recommendation. "The contextual evidence review found that many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, psychological therapies such as [cognitive behavioral therapy, or CBT], and certain interventional procedures can ameliorate chronic pain."

    The CDC guidelines were created in response to growing rates of opioid use disorder and opioid overdose, a problem fueled by ever-increasing rates of opioid prescriptions written by primary care providers—approximately 259 million prescriptions written in 2012 alone. In its introduction to the guideline, CDC cites from 1 study that among 15- 64-year-olds who received opioids for noncancer pain, 1 in 550 died from an opioid-related overdose at a median of 2.6 years from their first prescription.

    A draft version of the guidelines were published in late 2015 as part of a CDC call for comments. APTA responded with strong support for the recommendations, writing 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."

    Other stakeholders were less enthusiastic. According to a report from National Public Radio, some critics questioned the CDC recommendation against using opioids as a first-line treatment for chronic pain.

    In that NPR report, Debra Houry, director of CDC's National Center for Injury Prevention and Control, responded by pointing to weak evidence supporting the benefits of opioids for chronic pain and growing evidence pointing to the risks. "We have decided that because of that, and the uncertain benefits of opioids, that continuing to prescribe them for chronic pain is not warranted," Houry said. "On the other end, nonopioids, there is evidence for their benefits."

    In addition to the statement around first-line treatment, the CDC guideline includes recommendations that address the importance of establishing treatment goals, discussing risks of opioids with patients, choosing appropriate dosage and release factors, and conducting thorough follow-up assessments once a patient has been prescribed an opioid. The guidelines are not intended to apply to opioid use related to patients with cancer, palliative, or end-of-life care.

    News of the CDC guidelines spread quickly, with major media outlets including Newsweek, USA Today, The Wall Street Journal, and others reporting on the recommendations that arrive amidst increased national attention on the epidemic of opioid abuse and heroin use across the country. APTA is participating in a White House initiative to address the problem through, among other things, increased public awareness.

    Those APTA public awareness efforts include a page on MoveForwardPT.com, the association's website for consumers looking for information on physical therapy, with information on the risks of opioids and physical therapy's role in the treatment of pain.

    In addition to the guideline, CDC also released a checklist and fact sheet that outline the basics of the larger document. Both stress that nonopioid therapies should be "tried and optimized" before considering an opioid prescription as well as during reassessment of a patient who has received a prescription for opioids.


    • Been taking Glucosamine Chondroitin MSM for 2 years now for my osteoarthritis prescribed by my osteo doctor after a series of blood tests and after 6 months of continuous taking I was agaagain advised to have 10 laboratory tests and luckily all result proved normal. Glucosamine is my maintenance and it relieves me of knee pain, but my legs are now deformed but not so severe shape now looks like a pair of japanese legs, what should I do to bring back the original shape of my pair of legs, what would you recommend. Thank you

      Posted by Evagenia F. Delloso on 3/17/2016 9:15 PM

    • You showed 1 study and the range of age should be a red flag from the beginning. I have tried alternative methods as opposed to taking opiods. Didn't work! I believe you are pumping up physical therapy as a cure all and I've tried both. Sorry to say physical therapy isn't the magic answer. If anything this article is trying to push people towards physical therapy which makes me wonder the true motive behind the article. Myself would love to no longer take opiods but for right now to me and my family doctor this is the temporary solution to severe pain. My advice is have faith in your family doctor and if you question the diagnosis....get another opinion. Just because you follow your doctors recommendation won't magically turn you into an addict let alone have you chasing heroin. C'mon...really.?

      Posted by Scott Widhalm on 3/18/2016 1:44 AM

    • The US Centers for Disease Control and Prevention's (CDC's) 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 3/21/2016 3:15 PM

    • I think this is a great push for PT! In my practice, I never discourage patients from taking opioids...once they've tried treatments that can be just as effective (i.e. physical therapy) without the nasty side effects of addiction, GI distress, muscle wasting, etc. I often tell patients, however, that if PT clearly isn't working, then it is absolutely appropriate and indicated that they follow-up again with their PCP or referring physician (if there is one) to discuss the options of pain medication that includes opioids. I don't think this article or the CDC report is saying all opioids are bad all the time, but what it is saying is that there are other, safer options to try BEFORE jumping to opioids... I think that's a great order of operations, great for safety, and great for our patients.

      Posted by Mark Brauweiler -> BKP`EG on 3/21/2016 5:13 PM

    • the article states "first line" not only approach, but if you can do exercise to protect joints, practice good body mechanics, and are still in pain, THEN go for pharmaceuticals and other interventions. it makes sense to try more conservative (less negative side affects) approaches initially; no one is telling you to avoid opioids, but to prescribe safer alternatives first.

      Posted by maria on 3/21/2016 7:19 PM

    • Now if insurance will give patients more affordable copays and coinsurance amounts for regular PT, that would be a great help. I don't think medication should be automatically ruled out, but making PT something that the average Joe can afford would be a great benefit. The best physical therapy results come from regular visits to the physical therapist as well as "homework". But it ain't cheap for a lot of people. On the other hand, many pain medications can be obtained for a very reasonable price. But there's also another factor--some people simply will not put in the work required for a physical therapy regimen. We can try to deny it, but in some cases, it is true.

      Posted by Brenda Jackson on 3/21/2016 7:58 PM

    • Thank you APTA for supporting us and CDC for supporting non-opioid interventions. I am not opposed to opioids being needed, but it should be with a plan to restore manageable levels of pain without them eventually. But, PTs need to get up to better speed dealing with the complexities of chronic pain. It's not sports med. Exercise and manual therapy need a more robust framework to address the frequent presence of trauma, CNS de-regulation, aspects of a spectrum of PTSD type influences, altered brain-body maps, much reduced kinesthesia etc. Here is the link to a lecture on this specific topic of treating chronic pain in PT which I gave last year. http://forms.aweber.com/form/72/1209146772.htm You will need to give your email to gain access. And you will be able to receive my writing on the topic of treating chronic pain. I encourage you to reach out and do this if you are interested in better helping your clients and getting a fuller perspective on some of what is keeping them in pain that is relevant to PT practice. I can be reached at rachel@MindBodyPhysicalTherapy. I am passionate about sharing my 30+ years of clinical experience in this area with you. Here's the url again. Let's connect. http://forms.aweber.com/form/72/1209146772.htm Rachel

      Posted by Rachel Katz -> ?IX]> on 3/22/2016 11:16 AM

    • In response to Scott Widhalm. The age range is 18 years to the end of life with the exclusion of those on palliative care. No red flags there. In reference to yourself, opiods my be warranted but then you are just a case study; basically an n of 1. We have known for a long time that we have an issue with opiod use in the USA. It is a cultural phenomenon. We need healthier more effective treatment paths and physical therapy is one of them.

      Posted by Chuck Brockman on 3/23/2016 12:18 PM

    • It is the Drs that have in the past as some continue to do, Give them out like candy, a lot have been shut down in Florida as well as other states, but years ago this epidemic was started, and nothing can be done about the past. The only problem with Physical Therapy is people are to lazy to do the many reps of several exercises, Required Daily for the rest of there lives. So Much Easier to Just Take a couple pills !!! Not Me off to do my exercises !! for the Second Time Today !!

      Posted by John Newcomb on 3/31/2016 3:37 PM

    • I have osteo arthritis severe osteoporas and several fractures from falls besides disenegrated disc disease. I have major chronic pain and do not take any pain meds due to my sensitivity to most meds. I started PT after a recent compressed fracture at L2 and PT is a joke. Moist heat stim ( I have my own tens unit) some ultra sound nothing else. It's a joke and I just turned 65 so they are billing Medicare and not helping me:( I'm depressed with constant pain any advice?

      Posted by Mary on 6/17/2016 9:24 AM

    • To Mary, find a better PT at a clinic where patient care is priority and manual therapy is the focus. A certified manual therapist is what you are looking for. It saddens me that moist heat, e-stim, and ultrasound are your experience with PT. I am a certified manual physical therapist and I don't use any of these modalities. PT can be very beneficial, but just like in all areas of life, there are a few bad apples which are just out for your money. I hope you will reconsider your view on PT. Remember you don't have to go to the PT that your MD refers you to. You have a choice. Do your research and find a good one. You won't regret it.

      Posted by Justin on 11/28/2016 2:26 PM

    • Great article. For those who have tried PT without results, as others above have stated, the first question is what did they do at PT? If, as in one example here, all they did was heat/ultrasound/ice and a bit of exercise, that isn't good PT, yes, is a joke, and a waste of your time and money. But it you have a therapist who does manual hands-on care, works on your joints, muscles, and fascia to restore painfree motion, then supports that with exercise, results are undeniable. Not all PT is created equal and all it takes is a bit of research to find the right one who will take awesome care of you. I constantly hear "I didn't know PTs could do that" from my patients, especially when they've had substandard care in the past. Don't give up!!

      Posted by Dr Jesse Roles, PT, DPT, MTC on 2/1/2017 1:54 PM

    • Brenda you are correct. Average copays for methadone 5 to 10 dollars. PT visit specialist is 50 to 100 per visit. Very expensive. If you have internal damage such as I have opioids made me able to function contribute to society do work around the house etc heck even go back to school. Methadone has sharpened my cognitive abilities to where I received all A's in critical thinking classes. I 5hank my doctor for me being able to come off Medicare and work which makes me feel good. Opioids need to remain as a critical tool in pain management. Stop attacking the I'll and thier Physicians rather stop the billions of illegal drugs from coming over the border. This is the real problem.

      Posted by Rick on 3/13/2019 5:00 PM

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