The American Physical Therapy Association (APTA) is undertaking an anti-opioids campaign touting the benefits of Physical Therapy (PT) over highly addictive pain meds. The campaign is getting some negative buzz from opioid users but they, as well as others in the field, have some valid, statistical research on how PT can work better than pain meds. As with most issues, there are two sides to all opinions. This is how Excellence in Rehabilitation feels.
I’m not taking the stand that opioids should NEVER be used but the CDC released opioid prescription guidelines in March 2016 recognizing that prescription opioids are appropriate in certain cases, including cancer treatment, palliative care, and end-of-life care, and also in certain acute care situations—if—and it’s a big if—properly dosed.
So when could PT trump opioid use; or at the very least help reduce it?
- When the risk of the opioid outweighs the benefit. Using opioids for pain relief can include some horrible side effects, including depression, overdose, and addiction. And stopping the opioids can cause severe withdrawal symptoms. Consider whether long-term benefits outweigh the risks. The CDC states, “Even in cases when evidence on the long-term benefits of non-opioid therapies is limited, ‘risks are much lower’ with non-opioid treatment plans.”
- When the pain becomes chronic (defined as lasting beyond 90 days). At that point, opioids may only be masking the pain where non-opioid therapies “are preferred” for chronic pain according to the CDC. Again, weighing benefit to risks, PT administered by a clinician could lead to greater benefits in both pain and function, and result in lowered risk to the patient.
- When mental health issues exist. A study supported by the National Institute of Drug Abuse of the National Institutes of Health showed a link between mental health, opioid use, and opioid risk factors citing those with higher negative affect (a constellation of anxiety, depression, and catastrophizing cognitive style) were at a higher risk of opioid misuse. Subjects in the high risk group also tended to have a more frequent history of substance abuse and every subject in the high group had a psychiatric diagnosis of some type of an affective disorder. Identifying patients with affective disorders could be key in implementing PT to replace opioid use.
- When a reduction in pain is possible without pain medication. The APTA shows a JAMA Network Open article that reports early Physical Therapy was associated with a reduced risk of any opioid use in all 4 conditions tested: a 16% drop for knee pain patients, a 15% reduction for those with shoulder pain, 8% for neck pain, and 7% for low back pain. Among patients who were prescribed (and used) opioids, early Physical Therapy seemed to have an association with fewer pills taken for 3 of the 4 conditions.
- To follow expert recommendations. The CDC recommends non-opioid treatment as a primary method to address chronic pain, including low back pain. Physical therapy is considered a safe alternative to manage chronic low back pain.
One review of the research from Oregon Health and Science University found that rates of opioid prescribing in the US and Canada are two to three times higher than in most European countries. “Opioids do not seem to expedite return to work in injured workers or improve functional outcomes of acute back pain in primary care.” And for chronic back pain, there is “scant evidence of efficacy…Opioids seem to have short-term analgesic efficacy for chronic back pain, but benefits for function are less clear.”
According to the APTA, part of the problem with patients seeking PT is the barrier to entry. They say “current policies create barriers for patients seeking physical therapist treatment. In most cases, it’s easier and less expensive for physicians to prescribe opioids and for patients to receive opioids.” Insurance providers may require a primary care provider referral, which, while beneficial, may delay physical therapy. And the Duke Clinical Research Institute says high co-payments can also be a barrier—often, the co-payment for a one-month opioid prescription is less than the co-payment for a single session with a chiropractor or physical therapist.
Based on this research and my 20+ years as a Physical Therapist and Instructor in the field, for me, the biggest takeaway is that early Physical Therapy may be an option for several musculoskeletal conditions. If preventing long-term opioid use is a treatment goal, the research all supports that those receiving early Physical Therapy had fewer long-term opioid use rates.
If knowledge is power, that’s important information for Physical Therapists to have in their treatment toolbox.