Caroline Collins: Physical Therapy is a Safe Alternative to Opioids for Effective Pain Management
No one wants to live in pain. Nor do we want to put our health at risk in the quest to be pain-free. Consumers should receive appropriate pain treatment based on a careful consideration of the benefits and risks of treatment options. However, opioid prescribing patterns reveal that too often that is not the case. The point of crisis is not the best time to research one’s options; the savvy health care consumer is prepared with knowledge before presenting their complaint to the doctor. Scary statistics saturate the daily news, but the focus of this article is on practical alternative solutions to empower the consumer who is dedicated to making their own decisions about their health.
What are opioids?
Opioids are a class of drugs that act on the nervous system to relieve moderate to severe pain. They are used in anesthesia and in short and long-acting forms; they come in tablets, capsules or liquid. Available legally by prescription, they include oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, Percocet®, Percodan®, Tylox® and Demerol® among others. Opioids also include the illegal drug heroin and synthetic formulas such as fentanyl.
They don’t work for all kinds of pain, and their pain control effect tends to diminish over time, meaning higher doses are needed to produce the desired effect, a condition known as opioid tolerance. Habit-forming, they are prone to being abused, leading to physical dependence, which means without it, the body will suffer withdrawal symptoms. The term narcotic is broader and includes opioids, along with other substances that “blunt the senses, as opium, morphine, belladonna, and alcohol, that in large quantities produce euphoria, stupor, or coma, that when used constantly can cause habituation or addiction (physical craving), and that are used in medicine to relieve pain, cause sedation, and induce sleep.” (www.dictionary.com) “Narcotic” is also used colloquially to describe anything that induces a soothing or numbing effect or influence, such as television.
There are many serious contraindications and warnings about opioid use. Taking heed of label directions is critical. Because it slows breathing, beware of using if there are underlying breathing problems like asthma, or along with other medications or alcohol that also depress breathing or cause drowsiness. The combination can be deadly. Damaging effects on kidneys, stomach and liver can also become life-threatening. Taking opioids during pregnancy may cause dangerous withdrawal symptoms in the newborn, inhibit normal mother-child bonding after birth, and impair the ability to care for a child.
Is there an appropriate use of opioids?
In certain limited situations, dosed properly, prescription opioids can be an appropriate part of medical treatment. These cases may include people in cancer treatment, palliative care, and end-of-life care, as well as certain acute care situations, under close supervision. Opioids are not considered an appropriate course of action for the chronic pain conditions driving many to their doctors. Such conditions including back or neck pain, osteoarthritis of the hip or knee, and fibromyalgia are often accompanied by problems with function. Adding an opioid to the mix does nothing to restore function, and can indeed impede normal life functioning even further.
CDC Sounds the Epidemic Alarm
Opioids are commonly, and increasingly, prescribed for pain, despite the risk of multiple adverse health outcomes, including fatality, and the availability of safer, more effective treatments. A common complaint driving many to seek medical help is back pain, a condition that neither necessitates nor generally responds well to opioids.
According to the Centers for Disease Control and Prevention (CDC), sales of prescription opioids have quadrupled in the United States, killing 145 people a day. Short of death, adverse effects include depression, overdose, and addiction, plus withdrawal symptoms when use is stopped. People addicted to prescription opioids are 40 times more likely to become addicted to heroin. In response, the CDC released opioid prescription guidelines in March 2016, urging providers to reduce the prescribing of opioids in favor of safe, conservative, lower cost alternatives such as non-opioid analgesics and physical therapy.
The responsible consumer wants to know what all the options are, and partner with their health care provider to choose the path that is right for him or her. While a quick fix can be tempting, it is important to know the hidden costs before succumbing. Alternate treatment options may require more time and expense initially, but they are proven to be more effective in the long term, while promoting better quality of life and empowering the patient to manage their own pain autonomously.
In 2012, health care providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have their own bottle of pills (https://www.ncbi.nlm.nih.gov/pubmed/24990489). Rates vary widely among states, seemingly random patterns unexplainable by the underlying health status of their populations, indicating a lack of consensus among clinicians on appropriate opioid prescribing (https://www.ncbi.nlm.nih.gov/pubmed/24990489).
From 2000 to 2010, the percentage of patients presenting with pain who received an opioid prescription nearly doubled, to almost 20%. (https://www.ncbi.nlm.nih.gov/pubmed/24025657). At the same time, non-opioid analgesic prescribing for all pain complaints remained relatively stable (26-29%). Prescribing of non-opioid analgesics dropped for musculoskeletal pain visits from 38% (2000) to 29% (2010).
What is musculoskeletal pain?
Musculoskeletal pain refers to pain often resulting from an injury to the bones, joints, muscles, tendons, ligaments, or nerves. This can be caused by jerking movements, car accidents, falls, fractures, sprains, dislocations, and direct blows to the muscle. Musculoskeletal pain can result from overdoing physical labor, sports injuries or excessive/inappropriate exercise. https://my.clevelandclinic.org/health/diseases/14526-musculoskeletal-pain
What about non-opioid pain medications?
Analgesics are pain-relieving substances that can be taken orally or topically. Unlike opioids, they do not incur the serious risks of addiction and death, but they do carry other risks and contraindications, and must be taken as directed. The January 2018 issue of Costco Connection featured a handy primer on how to choose the right over-the-counter analgesic for the situation, and consideration of prescription-strength pain relievers.
By its name, nonsteroidal anti-inflammatories (NSAIDS) indicate they are meant for pain caused by inflammation, including superficial aches and pains like toothaches, headaches, backaches, strains and also arthritis. They include ibuprofen, naproxen and aspirin. A different type of analgesic, acetaminophen can also treat pain from headaches and arthritis, but it does not reduce inflammation/swelling.
The most common side effect of NSAIDS is stomach upset. They can react with blood thinners and are metabolized through the kidneys, so a patient with kidney disease will likely be advised against using NSAIDs. Acetaminophen doesn’t affect the stomach like NSAIDS do, but large doses and long-term use can damage the liver.
Nerve or neuropathic pain tends to be experienced as sharp, shooting sensation or a pain that radiates from one place to another, and may not respond to OTC analgesics. In those case, a prescription NSAID may be recommended. This is also where opioids may be introduced, so remember the warnings reviewed above, and recognize that long-term use is only recommended for limited situations such as chronic cancer pain, and end-of-life. Antidepressants and anti-seizure drugs may also be considered for neuropathic or chronic pain that doesn’t respond to more conservative medications. Potential side effects from prescription drugs comprise a lengthy varied list, but the most common are sedation, nausea, vomiting, constipation and addiction.
Physical Therapy and Education
An alternative treatment for pain without the side effects and hazards of pain-killing pills is physical therapy (PT). A well-respected discipline based on evidence, the therapist takes an individual-centered approach, considering the needs of the whole body to regain a balanced state in which self-healing and improved function are enabled. Education is key. Movement therapy, including appropriate home exercises, is just one of many modalities available to physical therapists in designing a customized treatment plan.
So why is referral for PT not more often considered by providers before prescribing pain pills? There is a widespread perception that patients want the quick fix, the pill prescription. Surveys however show that when asked, consumers would actually prefer to avoid prescription drugs for pain, especially when they know the facts and options. So whether or not your provider asks your preference, if you come to your appointment prepared with knowledge, you will be better able to communicate your needs and partner more effectively with your provider for the best outcome.
“People who desire to manage pain by treating the source, not masking it, and who do not want to risk adverse side effects that interfere with the normal functions of life, are good candidates for PT,” says Tallahassee physical therapist Rene Luna, clinic director, FYZICALR Therapy and Balance Centers. “We see many patients with work-related injuries who are motivated to return to work sooner, without being addled mentally or physically by pain medications.”
Even if surgery is eventually recommended, there is a growing body of evidence that starting with physical therapy beforehand improves outcomes. While physical therapists are known as hands-on, movement specialists, evidence is beginning to suggest their ability to teach can improve outcomes and reduce health care costs as well.
In a study published in the journal Spine (Preoperative pain neuroscience education for lumbar radiculopathy – August 15, 2014), a group of individuals who were undergoing surgery of the lumbar spine were divided into two groups and post-surgery outcomes were compared. Prior to surgery, half of the participants received the typical pre-surgical care. The other half received specialized education from a physical therapist on the neuroscience of pain. The researchers followed up with the participants one year after surgery and found the group who received a single, educational session from a physical therapist, viewed their surgical experience much more favorably, and accounted for 45% lower health care costs following surgery.
What about low back pain?
If you have experienced low back pain, you are not alone. According to a 2012 survey by the American Physical Therapy Association (APTA), 61 percent of Americans said they have experienced low back pain, and of those 69 percent felt it has affected their daily lives. The good news is that most cases of low back pain are not serious and will respond well to conservative, proven treatments such as physical therapy.
A systematic analysis of 23 separate studies evaluating various interventions for low back pain was published in JAMA Internal Medicine (January 11, 2016 issue). The review linked exercise to a 35% reduction in the risk of a low back pain episode. The review (Prevention of Low Back Pain: A Systematic Review and Meta-analysis https://www.ncbi.nlm.nih.gov/pubmed/26752509) found that combining exercise with education provides even better results: a 45% risk reduction. Other interventions, including education alone, back belts, and shoe insoles, did not make a noticeable difference.
Additionally, exercise was found to reduce sick leave time for low back pain by 78%.
Physical therapy is a cost effective first choice in an era when all too often back pain is over-treated with narcotics or unnecessary imaging scans that yield higher costs without benefit. Physical therapists partner with patients, their families, and other health care professionals to manage pain through movement and exercise.
Before accepting a prescription for opioids, you owe it to yourself to consider safer alternatives.
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