A Multidimensional Approach to Combating Chronic Pain and Opioid Crisis

A




Multidimensional Approach to Combating Chronic Pain and Opioid Crisis

Opioids are a class of drugs that involve masking pain as they work by blocking the signal that let the brain know that a painful stimulus was encountered. Opioid overuse and abuse in the United States is a public health crisis. Our country is facing an epidemic of mass proportions that from 1999-2014 cost over 165,000 individuals their lives.

¹

Furthermore, opioid-related fatalities rose by 345% from 2001 to 2016.

²

In the year 2012, there were 259 million prescriptions filled for opiate based drugs, more than the entire population of adults in the country.

¹

While very effective at masking pain, opioid based drugs can have very serious side effects including developing a tolerance, being highly addictive, and having a high rate of abuse, which can lead to a condition called opioid use disorder.

¹

The opioid crisis began due to a multitude of factors including haphazard and aggressive opioid marketing, poor insight into the addictive quality of the opioid-based medications, lack of education in prescribing providers, lack of initial oversight by the government, but most importantly, the success of opioids as an incredibly effective pain blocking drug.

^{1, 3}

This major public health issue is profoundly complicated as patients need their pain to be treated fairly and compassionately, but at the same time minimizing the risk of abuse. Due to the complex nature of this issue, a multidimensional approach including, physical therapy, psychotherapy, patient education, non-opioid pain medications or reduction of opioids, and lifestyle changes as a means to reduce both pain and abuse of opioids.

Opioids work to block the sense of pain by inhibiting the release of neurotransmitters that allow the painful message to reach the brain.

⁴

The mechanism involves opioid molecules binding to opioid-receptors in the presynaptic terminal inhibiting the release of neurotransmitters.

⁴

While this isn’t the only effect that opioids have on the body, it is the main action in blocking pain.

⁴

Opioids have a high risk for abuse because they can change mood, elicit physical dependance, are relatively fast at building up a tolerance, and upon being introduced to the system elicit a “reward” effect.

⁴

These factors can contribute to using the drug compulsively and abusing it. Different opioids have different relative strengths, and are all compared to morphine through the use of morphine milligram equivalents (MME).

¹

This is significant as patients who took 36 MME or less had a .7% chance of abusing opioids, while patients that took greater than 120 MME had a 6.1% chance of abusing opioids, and patients taking greater than 200 MME have a 3.1% chance of dying from an opioid overdose.

¹

The dramatic rise of opioids actually began as a proposed solution to another health crisis going on. In the mid 1990’s there was a lack of support and treatment for patients dealing with a lot of pain, especially patients with cancer pain and patients in end of life care.

¹

This led to companies to begin creating opioid based medication as a solution to this problem. Purdue Pharmaceuticals, the company that created Oxycontin, is perhaps the largest and most significant company involved in the opioid crisis. In 1995 Purdue created Oxycontin, which is an opioid based pain blocker that is twice as strong as morphine, but what made it unique at the time was that it was the first slow release opioid providing relief for twelve hours, meaning that patients only had to take it twice a day.

³

This also meant that there was much more of the drug in one pill when compared to other opioid medications at the time. Oxycontin was intended to be safer than other opioids due to its slow release nature, however individuals intending to abuse the medication could crush it up so it all absorbed immediately providing a “high.”

³

Purdue’s real contribution to the epidemic, however, was due to the nature of their aggressive marketing strategies. They promoted Oxycontin not only to oncologists and pain specialists, but to primary care physicians as well.

³

They also promoted the drug as pain relief for any kind of moderate pain, rather than the original intention, which led to primary care practices prescribing more than half of the prescriptions for Oxycontin in 2003, which at that point had become the most prescribed narcotic medication on the market.

³

Finally, Purdue used false and misleading advertisements in marketing this drug both to the public and to physicians by downplaying the addictive nature and harmful effects causing them to be cited by the FDA twice.

³

All of this led to an incredibly dangerous situation as primary care physicians were not sufficiently trained in pain management compared to pain specialists and tended to over-prescribe, and to prescribe as an initial treatment for many types of pain before exploring non-narcotic treatments.

³

Many Americans struggle to deal with pain due to many different ailments. In a study conducted in 2016, it is estimated that 55.7% of US adults reported some kind of pain in the past month.

⁵

The feeling of pain begins when primary nociceptive sensory neurons are influenced either by a strong potentially dangerous external source or by chemicals released as a result of the inflammation cascade.

⁴

Through action potentials and the release of neurotransmitters, these neurons transmit this nociceptive information to the brain, to which the brain responds with feelings of pain.

⁴

The most common type of pain is acute pain. this pain is short lived and is a natural defense mechanism against noxious stimuli, and allows people to heal injuries properly.

Chronic pain lasts much longer than acute pain and is experienced by 14.6% of adults. It is defined as lasting longer than three months past normal tissue healing, and can be caused by a plethora of different medical conditions, diseases, or have unknown causes.

¹

According to the Center for Disease Control (CDC) “there are clinical, psychological, and social consequences” of chronic pain that can cause “low work productivity, reduced quality of life, and stigma.”

¹

A lot of patients with chronic pain are prescribed opioid medications. This is very dangerous because the opioids do nothing to treat the cause of the pain, just to temporarily block it. Due to the long lasting nature of chronic pain these patients tend to be taking opioids for long durations, opening up the door to tolerance, physical dependence, and abuse.

⁶

In a study done in 2015, it was found that 61.5% of patients that had an opioid-related death were also diagnosed with chronic pain

⁶

.

Pain is such a big issue in this country which makes the opioid crisis all the more challenging. In its current recommendations, the CDC emphasizes only that short-term (>12 weeks) use of opioids is effective in treating pain unrelated to cancer or end of life.

¹

It recommends attempting treatments that are safer and treat the root of the issue.

¹

They concluded that for chronic pain, there was only very limited evidence that long-term opioid therapy may be effective, and there was no evidence that long-term opioid use was more effective than non-opioid therapy.

¹

As mentioned above, a multidimensional approach to treating chronic pain can provide a safer, more effective, and longer lasting treatment as compared to opioid use.

Many people know that physical therapy is known to help relieve pain and improve function, however many do not realize how accessible it is, or that they do not need a doctor’s prescription to obtain treatment. Furthermore,  many people do not know that physical therapy is recommended as a first line of defence when it comes to pain, especially chronic pain. A study was done in 2018 that compared outcomes of patients with back pain who either saw a physical therapist as a first line of defense, or saw a physical therapist later in treatment or not at all.

⁷

There were very substantial results that indicated that patients who saw a physical therapist first were 89.4% less likely to obtain an opioid prescription.

⁷

Additionally, they were 27.9% less likely to need expensive advanced imaging, and 14.7% less likely to go to the emergency department because of this issue.

⁷

Finally, the patients on average had much lower out of pocket costs for treatment.

⁷

Physical therapy can help patients manage their pain through many different means. First and foremost, A physical therapist can develop and supervise an exercise plan that will help improve balance, strength, conditioning, and other pain causing weakness.

⁸

A study done concluded that patients who exercised at least once a week were 20% less likely to have chronic widespread musculoskeletal complaints.

⁹

Physical therapists can also help treat pain through manual therapy using manipulations to decrease inflammation, increase flexibility, and improve mobility.

⁸

Finally, physical therapists can educate the patient on proper movement and pain education so that the patient can go about their daily activities with as minimal pain possible.

⁸

Physical therapists are an integral part of a multidisciplinary team aimed at reducing pain in patients.

Psychotherapy is also very important in helping patients deal with pain. Patients that undergo cognitive behavior therapy (CBT) have positive results when it comes to disability and catastrophic thinking.

¹

In a study done by the military in 2013, a group of soldiers were given psychosocial education on low back pain and another group was not.

¹⁰

The education was meant to alleviate concern and threat of low back pain.

¹⁰

The results of the study showed that the group that received the psychosocial education had marginally lower health care costs over a two year period compared to the group that did not receive the education.

¹⁰

Patients with chronic pain are already at a high likelihood to develop depression and anxiety due to the nature of chronic pain.

¹

This should be a contraindication to opioid based medicine as a side effect of opioids is depression. In patients that died due to opioid overdose, 61.6% also filled a prescription for a benzodiazepine, and 59% for an antidepressant within the 12 months leading up to death.

⁶

It is noted that a lot of these patients used many different doctors and pharmacies.

⁶

This is very risky as those drugs and interact negatively and amplify each others effects.

¹

There are pharmacological means to treating pain besides opioids if other methods aren’t working. The CDC recommends acetaminophen, NSAIDS, and COX-2 inhibitors in treating patients for pain before using opioids.

¹

They also stated that certain anticonvulsants and antidepressants can play a role in reducing pain.

¹

There was a study done on 240 patients experiencing chronic pain and half of the group was prescribed opioid analgesics, and the other half used non-narcotic pain medicine and after 12 months there was no significant difference in pain related function.

¹¹

The researchers also saw that medication related side effects was much greater in the opioid group.

¹¹

This study shows that for long term pain, a patient is much better off avoiding opiates.

There are also research out there that shows positive outcomes in reducing or discontinuing opioid use in patients that are doing long term opioid therapy (LTOT).

¹²

A review was done on 67 different studies centered around LTOT and many of the studies reported positive outcomes with dose reduction.

¹²

Many of the studies looked at saw patients have improvements in pain severity, function, and quality of life.

¹²

This review shows that even if patients are already on LTOT they can have positive outcomes by reducing the dose or discontinuing LTOT in favor of other therapies.

In conclusion, pain is a very complex issue, but there are many different approaches when treating patients with pain before opioids are considered. Physical therapy provides patients not only with pain relief, but can help treat the source of the pain rather than mask the symptoms. It can also help patients learn how to move more effectively so that they can do their daily activities and work with less pain. Psychotherapy can help patients have a better perspective on their pain and be in the best head space to avoid abusing medication. Using non-opioid drugs instead of opioids can have similar outcomes without the negative side effects, and for long term users, a dosage reduction or transition to other therapies can have positive outcomes. Opioids are not evil drugs. They can help a great deal of patients dealing with pain related to cancer, as well as patients in the later stages of terminal illnesses who need palliative care. Opioids also have some proven use in treating severe short-term pain. However, the high risk of abuse, significant side effects, and dangers of opioids should leave them as an absolute last resort in noncancer pain management. The opioid crisis has gone on long enough. It is time for patients and physicians to choose a better, multidimensional way to manage pain.

1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.
   
   MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports
   
   . 2016;65:1-49.
2. Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. The Burden of Opioid-Related Mortality in the United States.
   
   JAMA network open
   
   . 2018;1:e180217.
3. United States. General Accounting Office. Prescription Drugs: OxyContin Abuse and Diversion and Efforts to Address the Problem. United States. General Accounting Office; 2003. Available from: http://digital.library.unt.edu/ark:/67531/metadc293500/.
4. Chahl LA. Opioids – mechanisms of action.
   
   Australian Perscriber
   
   . 1996;19.
5. Nahin RL. Estimates of Pain Prevalence and Severity in Adults: United States, 2012.
   
   Journal of Pain
   
   . 2015;16:769-780.
6. Olfson M, Wall M, Wang S, Crystal S, Blanco C. Service Use Preceding Opioid-Related Fatality.
   
   American Journal of Psychiatry
   
   . 2018;175:538-544.
7. Frogner BK, Harwood K, Andrilla CHA, Schwartz M, Pines JM. Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs.
   
   Health Services Research
   
   . 2018;53:4629-4646.
8. Hayhurst C. Moving Away From Opioid Reliance.
   
   American Physical Therapy Association.
   
   PTinMOTION; 2018:32-44. Available from:
9. Holth HS, Werpen HKB, Zwart J, Hagen K. Physical inactivity is associated with chronic musculoskeletal complaints 11 years later: results from the Nord-Trøndelag Health Study.
   
   BMC musculoskeletal disorders
   
   . 2008;9:159.
10. Childs, John D., PT, PhD, MBA, Wu SS, PhD, Teyhen, Deydre S., PT, PhD, Robinson ME, PhD, George, Steven Z., PT, PhD. Prevention of low back pain in the military cluster randomized trial: effects of brief psychosocial education on total and low back pain–related health care costs.
    
    Spine Journal, The
    
    . 2014;14:571-583.
11. Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial.
    
    JAMA
    
    . 2018;319:872-882.
12. Frank JW, Lovejoy TI, Becker WC, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review.
    
    Annals of internal medicine
    
    . 2017;167:181-191.

A




Multidimensional Approach to Combating Chronic Pain and Opioid Crisis

Opioids are a class of drugs that involve masking pain as they work by blocking the signal that let the brain know that a painful stimulus was encountered. Opioid overuse and abuse in the United States is a public health crisis. Our country is facing an epidemic of mass proportions that from 1999-2014 cost over 165,000 individuals their lives.

¹

Furthermore, opioid-related fatalities rose by 345% from 2001 to 2016.

²

In the year 2012, there were 259 million prescriptions filled for opiate based drugs, more than the entire population of adults in the country.

¹

While very effective at masking pain, opioid based drugs can have very serious side effects including developing a tolerance, being highly addictive, and having a high rate of abuse, which can lead to a condition called opioid use disorder.

¹

The opioid crisis began due to a multitude of factors including haphazard and aggressive opioid marketing, poor insight into the addictive quality of the opioid-based medications, lack of education in prescribing providers, lack of initial oversight by the government, but most importantly, the success of opioids as an incredibly effective pain blocking drug.

^{1, 3}

This major public health issue is profoundly complicated as patients need their pain to be treated fairly and compassionately, but at the same time minimizing the risk of abuse. Due to the complex nature of this issue, a multidimensional approach including, physical therapy, psychotherapy, patient education, non-opioid pain medications or reduction of opioids, and lifestyle changes as a means to reduce both pain and abuse of opioids.

Opioids work to block the sense of pain by inhibiting the release of neurotransmitters that allow the painful message to reach the brain.

⁴

The mechanism involves opioid molecules binding to opioid-receptors in the presynaptic terminal inhibiting the release of neurotransmitters.

⁴

While this isn’t the only effect that opioids have on the body, it is the main action in blocking pain.

⁴

Opioids have a high risk for abuse because they can change mood, elicit physical dependance, are relatively fast at building up a tolerance, and upon being introduced to the system elicit a “reward” effect.

⁴

These factors can contribute to using the drug compulsively and abusing it. Different opioids have different relative strengths, and are all compared to morphine through the use of morphine milligram equivalents (MME).

¹

This is significant as patients who took 36 MME or less had a .7% chance of abusing opioids, while patients that took greater than 120 MME had a 6.1% chance of abusing opioids, and patients taking greater than 200 MME have a 3.1% chance of dying from an opioid overdose.

¹

The dramatic rise of opioids actually began as a proposed solution to another health crisis going on. In the mid 1990’s there was a lack of support and treatment for patients dealing with a lot of pain, especially patients with cancer pain and patients in end of life care.

¹

This led to companies to begin creating opioid based medication as a solution to this problem. Purdue Pharmaceuticals, the company that created Oxycontin, is perhaps the largest and most significant company involved in the opioid crisis. In 1995 Purdue created Oxycontin, which is an opioid based pain blocker that is twice as strong as morphine, but what made it unique at the time was that it was the first slow release opioid providing relief for twelve hours, meaning that patients only had to take it twice a day.

³

This also meant that there was much more of the drug in one pill when compared to other opioid medications at the time. Oxycontin was intended to be safer than other opioids due to its slow release nature, however individuals intending to abuse the medication could crush it up so it all absorbed immediately providing a “high.”

³

Purdue’s real contribution to the epidemic, however, was due to the nature of their aggressive marketing strategies. They promoted Oxycontin not only to oncologists and pain specialists, but to primary care physicians as well.

³

They also promoted the drug as pain relief for any kind of moderate pain, rather than the original intention, which led to primary care practices prescribing more than half of the prescriptions for Oxycontin in 2003, which at that point had become the most prescribed narcotic medication on the market.

³

Finally, Purdue used false and misleading advertisements in marketing this drug both to the public and to physicians by downplaying the addictive nature and harmful effects causing them to be cited by the FDA twice.

³

All of this led to an incredibly dangerous situation as primary care physicians were not sufficiently trained in pain management compared to pain specialists and tended to over-prescribe, and to prescribe as an initial treatment for many types of pain before exploring non-narcotic treatments.

³

Many Americans struggle to deal with pain due to many different ailments. In a study conducted in 2016, it is estimated that 55.7% of US adults reported some kind of pain in the past month.

⁵

The feeling of pain begins when primary nociceptive sensory neurons are influenced either by a strong potentially dangerous external source or by chemicals released as a result of the inflammation cascade.

⁴

Through action potentials and the release of neurotransmitters, these neurons transmit this nociceptive information to the brain, to which the brain responds with feelings of pain.

⁴

The most common type of pain is acute pain. this pain is short lived and is a natural defense mechanism against noxious stimuli, and allows people to heal injuries properly.

Chronic pain lasts much longer than acute pain and is experienced by 14.6% of adults. It is defined as lasting longer than three months past normal tissue healing, and can be caused by a plethora of different medical conditions, diseases, or have unknown causes.

¹

According to the Center for Disease Control (CDC) “there are clinical, psychological, and social consequences” of chronic pain that can cause “low work productivity, reduced quality of life, and stigma.”

¹

A lot of patients with chronic pain are prescribed opioid medications. This is very dangerous because the opioids do nothing to treat the cause of the pain, just to temporarily block it. Due to the long lasting nature of chronic pain these patients tend to be taking opioids for long durations, opening up the door to tolerance, physical dependence, and abuse.

⁶

In a study done in 2015, it was found that 61.5% of patients that had an opioid-related death were also diagnosed with chronic pain

⁶

.

Pain is such a big issue in this country which makes the opioid crisis all the more challenging. In its current recommendations, the CDC emphasizes only that short-term (>12 weeks) use of opioids is effective in treating pain unrelated to cancer or end of life.

¹

It recommends attempting treatments that are safer and treat the root of the issue.

¹

They concluded that for chronic pain, there was only very limited evidence that long-term opioid therapy may be effective, and there was no evidence that long-term opioid use was more effective than non-opioid therapy.

¹

As mentioned above, a multidimensional approach to treating chronic pain can provide a safer, more effective, and longer lasting treatment as compared to opioid use.

Many people know that physical therapy is known to help relieve pain and improve function, however many do not realize how accessible it is, or that they do not need a doctor’s prescription to obtain treatment. Furthermore,  many people do not know that physical therapy is recommended as a first line of defence when it comes to pain, especially chronic pain. A study was done in 2018 that compared outcomes of patients with back pain who either saw a physical therapist as a first line of defense, or saw a physical therapist later in treatment or not at all.

⁷

There were very substantial results that indicated that patients who saw a physical therapist first were 89.4% less likely to obtain an opioid prescription.

⁷

Additionally, they were 27.9% less likely to need expensive advanced imaging, and 14.7% less likely to go to the emergency department because of this issue.

⁷

Finally, the patients on average had much lower out of pocket costs for treatment.

⁷

Physical therapy can help patients manage their pain through many different means. First and foremost, A physical therapist can develop and supervise an exercise plan that will help improve balance, strength, conditioning, and other pain causing weakness.

⁸

A study done concluded that patients who exercised at least once a week were 20% less likely to have chronic widespread musculoskeletal complaints.

⁹

Physical therapists can also help treat pain through manual therapy using manipulations to decrease inflammation, increase flexibility, and improve mobility.

⁸

Finally, physical therapists can educate the patient on proper movement and pain education so that the patient can go about their daily activities with as minimal pain possible.

⁸

Physical therapists are an integral part of a multidisciplinary team aimed at reducing pain in patients.

Psychotherapy is also very important in helping patients deal with pain. Patients that undergo cognitive behavior therapy (CBT) have positive results when it comes to disability and catastrophic thinking.

¹

In a study done by the military in 2013, a group of soldiers were given psychosocial education on low back pain and another group was not.

¹⁰

The education was meant to alleviate concern and threat of low back pain.

¹⁰

The results of the study showed that the group that received the psychosocial education had marginally lower health care costs over a two year period compared to the group that did not receive the education.

¹⁰

Patients with chronic pain are already at a high likelihood to develop depression and anxiety due to the nature of chronic pain.

¹

This should be a contraindication to opioid based medicine as a side effect of opioids is depression. In patients that died due to opioid overdose, 61.6% also filled a prescription for a benzodiazepine, and 59% for an antidepressant within the 12 months leading up to death.

⁶

It is noted that a lot of these patients used many different doctors and pharmacies.

⁶

This is very risky as those drugs and interact negatively and amplify each others effects.

¹

There are pharmacological means to treating pain besides opioids if other methods aren’t working. The CDC recommends acetaminophen, NSAIDS, and COX-2 inhibitors in treating patients for pain before using opioids.

¹

They also stated that certain anticonvulsants and antidepressants can play a role in reducing pain.

¹

There was a study done on 240 patients experiencing chronic pain and half of the group was prescribed opioid analgesics, and the other half used non-narcotic pain medicine and after 12 months there was no significant difference in pain related function.

¹¹

The researchers also saw that medication related side effects was much greater in the opioid group.

¹¹

This study shows that for long term pain, a patient is much better off avoiding opiates.

There are also research out there that shows positive outcomes in reducing or discontinuing opioid use in patients that are doing long term opioid therapy (LTOT).

¹²

A review was done on 67 different studies centered around LTOT and many of the studies reported positive outcomes with dose reduction.

¹²

Many of the studies looked at saw patients have improvements in pain severity, function, and quality of life.

¹²

This review shows that even if patients are already on LTOT they can have positive outcomes by reducing the dose or discontinuing LTOT in favor of other therapies.

In conclusion, pain is a very complex issue, but there are many different approaches when treating patients with pain before opioids are considered. Physical therapy provides patients not only with pain relief, but can help treat the source of the pain rather than mask the symptoms. It can also help patients learn how to move more effectively so that they can do their daily activities and work with less pain. Psychotherapy can help patients have a better perspective on their pain and be in the best head space to avoid abusing medication. Using non-opioid drugs instead of opioids can have similar outcomes without the negative side effects, and for long term users, a dosage reduction or transition to other therapies can have positive outcomes. Opioids are not evil drugs. They can help a great deal of patients dealing with pain related to cancer, as well as patients in the later stages of terminal illnesses who need palliative care. Opioids also have some proven use in treating severe short-term pain. However, the high risk of abuse, significant side effects, and dangers of opioids should leave them as an absolute last resort in noncancer pain management. The opioid crisis has gone on long enough. It is time for patients and physicians to choose a better, multidimensional way to manage pain.

1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.
   
   MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports
   
   . 2016;65:1-49.
2. Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. The Burden of Opioid-Related Mortality in the United States.
   
   JAMA network open
   
   . 2018;1:e180217.
3. United States. General Accounting Office. Prescription Drugs: OxyContin Abuse and Diversion and Efforts to Address the Problem. United States. General Accounting Office; 2003. Available from: http://digital.library.unt.edu/ark:/67531/metadc293500/.
4. Chahl LA. Opioids – mechanisms of action.
   
   Australian Perscriber
   
   . 1996;19.
5. Nahin RL. Estimates of Pain Prevalence and Severity in Adults: United States, 2012.
   
   Journal of Pain
   
   . 2015;16:769-780.
6. Olfson M, Wall M, Wang S, Crystal S, Blanco C. Service Use Preceding Opioid-Related Fatality.
   
   American Journal of Psychiatry
   
   . 2018;175:538-544.
7. Frogner BK, Harwood K, Andrilla CHA, Schwartz M, Pines JM. Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs.
   
   Health Services Research
   
   . 2018;53:4629-4646.
8. Hayhurst C. Moving Away From Opioid Reliance.
   
   American Physical Therapy Association.
   
   PTinMOTION; 2018:32-44. Available from:
9. Holth HS, Werpen HKB, Zwart J, Hagen K. Physical inactivity is associated with chronic musculoskeletal complaints 11 years later: results from the Nord-Trøndelag Health Study.
   
   BMC musculoskeletal disorders
   
   . 2008;9:159.
10. Childs, John D., PT, PhD, MBA, Wu SS, PhD, Teyhen, Deydre S., PT, PhD, Robinson ME, PhD, George, Steven Z., PT, PhD. Prevention of low back pain in the military cluster randomized trial: effects of brief psychosocial education on total and low back pain–related health care costs.
    
    Spine Journal, The
    
    . 2014;14:571-583.
11. Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial.
    
    JAMA
    
    . 2018;319:872-882.
12. Frank JW, Lovejoy TI, Becker WC, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review.
    
    Annals of internal medicine
    
    . 2017;167:181-191.

A




Multidimensional Approach to Combating Chronic Pain and Opioid Crisis

Opioids are a class of drugs that involve masking pain as they work by blocking the signal that let the brain know that a painful stimulus was encountered. Opioid overuse and abuse in the United States is a public health crisis. Our country is facing an epidemic of mass proportions that from 1999-2014 cost over 165,000 individuals their lives.

¹

Furthermore, opioid-related fatalities rose by 345% from 2001 to 2016.

²

In the year 2012, there were 259 million prescriptions filled for opiate based drugs, more than the entire population of adults in the country.

¹

While very effective at masking pain, opioid based drugs can have very serious side effects including developing a tolerance, being highly addictive, and having a high rate of abuse, which can lead to a condition called opioid use disorder.

¹

The opioid crisis began due to a multitude of factors including haphazard and aggressive opioid marketing, poor insight into the addictive quality of the opioid-based medications, lack of education in prescribing providers, lack of initial oversight by the government, but most importantly, the success of opioids as an incredibly effective pain blocking drug.

^{1, 3}

This major public health issue is profoundly complicated as patients need their pain to be treated fairly and compassionately, but at the same time minimizing the risk of abuse. Due to the complex nature of this issue, a multidimensional approach including, physical therapy, psychotherapy, patient education, non-opioid pain medications or reduction of opioids, and lifestyle changes as a means to reduce both pain and abuse of opioids.

Opioids work to block the sense of pain by inhibiting the release of neurotransmitters that allow the painful message to reach the brain.

⁴

The mechanism involves opioid molecules binding to opioid-receptors in the presynaptic terminal inhibiting the release of neurotransmitters.

⁴

While this isn’t the only effect that opioids have on the body, it is the main action in blocking pain.

⁴

Opioids have a high risk for abuse because they can change mood, elicit physical dependance, are relatively fast at building up a tolerance, and upon being introduced to the system elicit a “reward” effect.

⁴

These factors can contribute to using the drug compulsively and abusing it. Different opioids have different relative strengths, and are all compared to morphine through the use of morphine milligram equivalents (MME).

¹

This is significant as patients who took 36 MME or less had a .7% chance of abusing opioids, while patients that took greater than 120 MME had a 6.1% chance of abusing opioids, and patients taking greater than 200 MME have a 3.1% chance of dying from an opioid overdose.

¹

The dramatic rise of opioids actually began as a proposed solution to another health crisis going on. In the mid 1990’s there was a lack of support and treatment for patients dealing with a lot of pain, especially patients with cancer pain and patients in end of life care.

¹

This led to companies to begin creating opioid based medication as a solution to this problem. Purdue Pharmaceuticals, the company that created Oxycontin, is perhaps the largest and most significant company involved in the opioid crisis. In 1995 Purdue created Oxycontin, which is an opioid based pain blocker that is twice as strong as morphine, but what made it unique at the time was that it was the first slow release opioid providing relief for twelve hours, meaning that patients only had to take it twice a day.

³

This also meant that there was much more of the drug in one pill when compared to other opioid medications at the time. Oxycontin was intended to be safer than other opioids due to its slow release nature, however individuals intending to abuse the medication could crush it up so it all absorbed immediately providing a “high.”

³

Purdue’s real contribution to the epidemic, however, was due to the nature of their aggressive marketing strategies. They promoted Oxycontin not only to oncologists and pain specialists, but to primary care physicians as well.

³

They also promoted the drug as pain relief for any kind of moderate pain, rather than the original intention, which led to primary care practices prescribing more than half of the prescriptions for Oxycontin in 2003, which at that point had become the most prescribed narcotic medication on the market.

³

Finally, Purdue used false and misleading advertisements in marketing this drug both to the public and to physicians by downplaying the addictive nature and harmful effects causing them to be cited by the FDA twice.

³

All of this led to an incredibly dangerous situation as primary care physicians were not sufficiently trained in pain management compared to pain specialists and tended to over-prescribe, and to prescribe as an initial treatment for many types of pain before exploring non-narcotic treatments.

³

Many Americans struggle to deal with pain due to many different ailments. In a study conducted in 2016, it is estimated that 55.7% of US adults reported some kind of pain in the past month.

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The feeling of pain begins when primary nociceptive sensory neurons are influenced either by a strong potentially dangerous external source or by chemicals released as a result of the inflammation cascade.

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Through action potentials and the release of neurotransmitters, these neurons transmit this nociceptive information to the brain, to which the brain responds with feelings of pain.

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The most common type of pain is acute pain. this pain is short lived and is a natural defense mechanism against noxious stimuli, and allows people to heal injuries properly.

Chronic pain lasts much longer than acute pain and is experienced by 14.6% of adults. It is defined as lasting longer than three months past normal tissue healing, and can be caused by a plethora of different medical conditions, diseases, or have unknown causes.

¹

According to the Center for Disease Control (CDC) “there are clinical, psychological, and social consequences” of chronic pain that can cause “low work productivity, reduced quality of life, and stigma.”

¹

A lot of patients with chronic pain are prescribed opioid medications. This is very dangerous because the opioids do nothing to treat the cause of the pain, just to temporarily block it. Due to the long lasting nature of chronic pain these patients tend to be taking opioids for long durations, opening up the door to tolerance, physical dependence, and abuse.

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In a study done in 2015, it was found that 61.5% of patients that had an opioid-related death were also diagnosed with chronic pain

⁶

.

Pain is such a big issue in this country which makes the opioid crisis all the more challenging. In its current recommendations, the CDC emphasizes only that short-term (>12 weeks) use of opioids is effective in treating pain unrelated to cancer or end of life.

¹

It recommends attempting treatments that are safer and treat the root of the issue.

¹

They concluded that for chronic pain, there was only very limited evidence that long-term opioid therapy may be effective, and there was no evidence that long-term opioid use was more effective than non-opioid therapy.

¹

As mentioned above, a multidimensional approach to treating chronic pain can provide a safer, more effective, and longer lasting treatment as compared to opioid use.

Many people know that physical therapy is known to help relieve pain and improve function, however many do not realize how accessible it is, or that they do not need a doctor’s prescription to obtain treatment. Furthermore,  many people do not know that physical therapy is recommended as a first line of defence when it comes to pain, especially chronic pain. A study was done in 2018 that compared outcomes of patients with back pain who either saw a physical therapist as a first line of defense, or saw a physical therapist later in treatment or not at all.

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There were very substantial results that indicated that patients who saw a physical therapist first were 89.4% less likely to obtain an opioid prescription.

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Additionally, they were 27.9% less likely to need expensive advanced imaging, and 14.7% less likely to go to the emergency department because of this issue.

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Finally, the patients on average had much lower out of pocket costs for treatment.

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Physical therapy can help patients manage their pain through many different means. First and foremost, A physical therapist can develop and supervise an exercise plan that will help improve balance, strength, conditioning, and other pain causing weakness.

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A study done concluded that patients who exercised at least once a week were 20% less likely to have chronic widespread musculoskeletal complaints.

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Physical therapists can also help treat pain through manual therapy using manipulations to decrease inflammation, increase flexibility, and improve mobility.

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Finally, physical therapists can educate the patient on proper movement and pain education so that the patient can go about their daily activities with as minimal pain possible.

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Physical therapists are an integral part of a multidisciplinary team aimed at reducing pain in patients.

Psychotherapy is also very important in helping patients deal with pain. Patients that undergo cognitive behavior therapy (CBT) have positive results when it comes to disability and catastrophic thinking.

¹

In a study done by the military in 2013, a group of soldiers were given psychosocial education on low back pain and another group was not.

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The education was meant to alleviate concern and threat of low back pain.

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The results of the study showed that the group that received the psychosocial education had marginally lower health care costs over a two year period compared to the group that did not receive the education.

¹⁰

Patients with chronic pain are already at a high likelihood to develop depression and anxiety due to the nature of chronic pain.

¹

This should be a contraindication to opioid based medicine as a side effect of opioids is depression. In patients that died due to opioid overdose, 61.6% also filled a prescription for a benzodiazepine, and 59% for an antidepressant within the 12 months leading up to death.

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It is noted that a lot of these patients used many different doctors and pharmacies.

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This is very risky as those drugs and interact negatively and amplify each others effects.

¹

There are pharmacological means to treating pain besides opioids if other methods aren’t working. The CDC recommends acetaminophen, NSAIDS, and COX-2 inhibitors in treating patients for pain before using opioids.

¹

They also stated that certain anticonvulsants and antidepressants can play a role in reducing pain.

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There was a study done on 240 patients experiencing chronic pain and half of the group was prescribed opioid analgesics, and the other half used non-narcotic pain medicine and after 12 months there was no significant difference in pain related function.

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The researchers also saw that medication related side effects was much greater in the opioid group.

¹¹

This study shows that for long term pain, a patient is much better off avoiding opiates.

There are also research out there that shows positive outcomes in reducing or discontinuing opioid use in patients that are doing long term opioid therapy (LTOT).

¹²

A review was done on 67 different studies centered around LTOT and many of the studies reported positive outcomes with dose reduction.

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Many of the studies looked at saw patients have improvements in pain severity, function, and quality of life.

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This review shows that even if patients are already on LTOT they can have positive outcomes by reducing the dose or discontinuing LTOT in favor of other therapies.

In conclusion, pain is a very complex issue, but there are many different approaches when treating patients with pain before opioids are considered. Physical therapy provides patients not only with pain relief, but can help treat the source of the pain rather than mask the symptoms. It can also help patients learn how to move more effectively so that they can do their daily activities and work with less pain. Psychotherapy can help patients have a better perspective on their pain and be in the best head space to avoid abusing medication. Using non-opioid drugs instead of opioids can have similar outcomes without the negative side effects, and for long term users, a dosage reduction or transition to other therapies can have positive outcomes. Opioids are not evil drugs. They can help a great deal of patients dealing with pain related to cancer, as well as patients in the later stages of terminal illnesses who need palliative care. Opioids also have some proven use in treating severe short-term pain. However, the high risk of abuse, significant side effects, and dangers of opioids should leave them as an absolute last resort in noncancer pain management. The opioid crisis has gone on long enough. It is time for patients and physicians to choose a better, multidimensional way to manage pain.

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