For a pitcher in New Mexico, it started with a foot injury. Knee surgery paved the way for a soccer player in California. A shattered right thumb opened the door for a lacrosse goalie in New Jersey.
Only in high school, each one of them began taking opioid pain relievers for their injuries and ultimately slid into heroin addiction.
The pitcher died of an overdose at 22. The soccer player dropped out of college, became a drug dealer, and introduced her younger brother to heroin before he died of an overdose. The goalie did time in jail.
Their harrowing stories – part of a 2015 Sports Illustrated special report, “How painkillers are turning young athletes into heroin addicts” – offer but a snapshot into the deadliest drug crisis in U.S. history.
The crisis has prompted calls for a renewed look at alternative pain treatments, including physical therapy.
In fact, the U.S. Centers for Disease Control and Prevention announced in 2016 that physical therapy and other non-drug, non-opioid options should be considered first when treating chronic pain.
HOW WE GOT HERE
The opioid crisis kills some 90 Americans every day, a rate roughly equivalent to that of auto fatalities, according to the New York Times. The crisis dates to the 1990s and the over-prescription of opioid painkillers such as OxyContin.
While this class of drugs is a powerful painkiller, it also is highly addictive. In many cases, prescription painkillers have led to addiction to less-expensive heroin. In 2014, a synthetic opioid called fentanyl – 50 times more potent than heroin – entered the drug supply.
The Sports Illustrated article noted that “80 percent of all users arrive at heroin after abusing opioid painkillers,” and that one in 15 people who take non-medical prescription painkillers will try heroin within the next 10 years.
“Anyone who is giving a kid an opioid prescription without serious oversight and supervision is out of their mind,” said a drug counselor and former college football player. “That stuff is like kryptonite.”
Of course, when it comes to age groups, the opioid crisis does not discriminate. The
percentage of opioid overdose deaths by age group in 2015, according to the Henry J. Kaiser Family Foundation:
Ages 0-24: 10 percent; ages 25-34, 26 percent; ages 35-44, 23 percent; ages 45-54, 23 percent; ages 55 and older, 19 percent.
One stark reality often overlooked in the opioid crisis is that while prescriptions for pain medications more than quadrupled between 1999 and 2010, “cumulative pain levels remained constant among Americans,” according to Sports Illustrated.
Far more painkillers were prescribed and consumed than pain prevalence and population warranted. In two years, Kermit, W.Va., received almost 9 million opioid pills – for a town of 400 people.
Blame for the opioid crisis falls broadly, from high rates of prescription, to television ads promoting drugs to consumers, to deficits in the amount of pain management training physicians receive and, in turn, how much of it they convey to patients.
According to a Washington Post-Kaiser Foundation survey:
• Only 62 percent of people received physician education pain-management strategies not involving drugs;
• 20 percent were not told about drug side effects;
• 34 percent who took pain medication for as little as two months became addicted.
Another factor is how Americans view pain, with a sense that life is “fixable,” as one college professor put it.
“I’m 51,” he said. “If I go to an American doctor and say ‘Hey – I ran the marathon I used to run when I was 30, now I’m all sore, fix me,’ my doctor will probably try to fix me.
“If you do that in France the doctor would say ‘It’s life, have a glass of wine – what do you want from me?’”
Philosophical arguments aside, much of the burden for fighting the opioid epidemic has fallen to federal and state governments.
In 2016, the U.S. Centers for Disease Control and Prevention issued voluntary, evidenced-based guidelines for physicians prescribing opioids for chronic pain.
As of August 2017, according to the National Conference of State Legislatures, 24 states had enacted legislation “with some type of limit, guidance or requirement related to opioid prescribing.” Most of this legislation limits first-time opioid prescriptions to a certain number of days’ supply, typically seven.
Meanwhile, 49 states have implemented a prescription drug monitoring program, or PDMP, which is an electronic database that tracks controlled substance prescriptions. It can provide timely information about prescription and patient behaviors.
PT’S BIGGER ROLE
Of course, given the crisis and the highly addictive nature of opioids, a case can be made that physical therapy has a bigger role to play.
Instructor Margaret Danilovich of the Northwestern University Feinberg School of Medicine – Department of Physical Therapy and Human Movement Sciences, argued that physical therapists are uniquely positioned to help.
She noted that almost 20 percent of health care visits are related to musculoskeletal problems, for which primary care physicians are not optimally trained.
“However, physical therapists are healthcare providers with specific training in musculoskeletal conditions,” she wrote. “With this expertise, physical therapists are skilled at identifying, diagnosing, and treating movement problems, including pain.”
She said physical therapists are “the most well trained health care provider to address pain and prevent unnecessary opioid use, but unfortunately, are often under-referred and under-utilized.”
One study found that only 10 percent of low back pain patients who visited a primary care physician between 1997 and 2010 were referred to physical therapy. Meanwhile, prescription rates for opioids during that period increased from 15 to 45 percent.
The American Physical Therapy Association has launched a national campaign – using #ChoosePT – to raise awareness about the risks of opioids and physical therapy as an alternative for long-term pain management.
Physical therapy not only can treat pain but also its underlying cause with exercises that focus on strength, flexibility, posture and body mechanics.
The association noted that even “a simple education session with a physical therapist can lead to improved function, range of motion, and decreased pain.”
Al-Hlou, Y., Katz, J., Jordan, D. “The facts on America’s opioid epidemic.” New York Times video, accessed on nytimes.com, December 2017.
“CDC: physical therapy, other non-drug, non-opioid approaches should be first-line treatment for chronic pain.” American Physical Therapy Association website (apta.org), March 16, 2016.
Danilovich, M. “The simple solution to fight the opioid epidemic.” The Hill, May 4, 2017.
Opioid overdose deaths by age group, 2015, chart on Henry J. Kaiser Family Foundation website (kff.org), accessed December 2017.
“Prescribing policies: states confront opioid overdose epidemic.” National Conference of State Legislatures website (ncsl.org), Sept. 8, 2017.
Wertheim, L.J., Rodriguez, K. “Smack epidemic: how painkillers are turning young athletes into heroin addicts.” Sports Illustrated, June 22, 2015.
Amos, O. “Why opioids are such an American problem.” bbc.com,
Oct. 25, 2017.
CASE STUDY: PHYSICAL THERAPY FOR CHRONIC LOW BACK PAIN
By Kati Mol
The patient, a 66-year-old male with a four-decade history of low back pain, was referred to physical therapy by his pain care doctor (physiatrist). A month prior to initial evaluation, a flare-up of this pain resulted in his use of a cane to walk. The patient received four injections to his low back, with minimal pain relief, three weeks prior to referral to PT. His only other current treatment was pain medication.
The patient was retired, living with his daughter in a two-story home, with his bedroom on the second floor. He used an electric chair to go up and down stairs. He was independent with all activities of daily living but required modifications because of his constant pain.
He tried to walk his two dogs daily but recently had been unable to because of his pain. He enjoyed swimming and martial arts, but he had been unable to participate in those activities for nearly 10 years because of the progression of his low back pain.
At the time of the evaluation, the patient complained of left-sided low back pain that radiated from his posterior lower extremity into his left foot. He noted some burning in the bottom of the foot.
The patient described the low back pain as sharp with movements but more often a constant dull pain that varied in intensity. His pain at worst was reported as 10/10 and at best 3/10. Aggravating factors were sitting for greater than 30 minutes, standing greater than 10 minutes, sit to stand, bending forward, squatting, and walking greater than five minutes.
The only easing factors were pain medicine, muscle relaxers and ice, but they achieved only minimal relief.
The patient presented in flexion (bent over) with increased weight bearing on right. There was noticeable atrophy of the left lower extremity and abdominals. Lumbar range of motion was grossly limited and painful; he was only able to reach his knees with his hands and then with increased pain. He presented with decreased strength and sensation on the left lower extremity and decreased core stability.
The physical therapist hypothesized that he suffered from a posterior disc derangement.
Initial treatment consisted of an extension-based program and patient education for chronic pain and posture. The patient was instructed to use a lumbar roll when seated to maintain a neutral spine. He also was taught proper form for getting in and out of bed to decrease stress on his low back.
By the third clinic visit, the patient ambulated without a cane and reported a significant decrease in radicular pain in his left lower extremity. While he could walk short distances without a cane or increased pain, he still had difficulty with longer distances. He noted an improvement with sitting while using a lumbar roll.
The patient’s extension-based program was progressed to further improve his range of motion. Because of decreased lumbar joint mobility, manual treatment was added to improve lumbar range of motion. The patient worked on further core stabilization exercises, along with proximal strengthening
of gluteal muscles. Further assessment showed limitations with hip mobility; he added hip stretches to address impairments.
By visit 10, the patient presented with 0/10 pain and was no longer using a cane. Because of the success with his physical therapy, he cancelled previously scheduled injections. He no longer relied on taking his pain pills and muscle relaxers.
He reported pain that at its worst was 1/10 and only in his low back. He noted that when he completed his home exercise program he could relieve his pain. He returned to walking his dogs and swimming. He said he felt “90 percent better” compared with his first visit.
His only limitations occurred with carrying more than three grocery bags or squatting to lift more than 10 pounds from the floor. Manual treatment addressed his hip mobility to help with squatting mechanics. He was seen for two additional weeks for progression of core and proximal stability and functional strengthening.
At discharge, the patient demonstrated good squatting and lifting mechanics without any increased pain. He stated that he had no functional limitations. The patient had developed good coping strategies and was independent with management skills and a home exercise program to control his symptoms.
RESEARCH ABSTRACT: OPIOIDS VS. PT FOR MANAGING CHRONIC LOW BACK PAIN
By Misty Seidenburg
Chronic low back pain (CLBP) is a widespread issue that leads to high economic costs and levels of disability. Comprehensive pain management includes medication, surgery, physical therapy and alternative interventions.
The use of narcotics is controversial as opioids have reported negative side effects, leading to poor functional levels and potential for abuse. With the rising opioid epidemic, non-drug alternatives are being explored rigorously.
The purpose of this study was to examine whether physical therapy had better outcomes than opioid use in managing chronic low back pain.
A review of medical literature from 2005 to 2013 found limited research into this topic. Because of this, the effectiveness of physical therapy and of opioids in treating CLBP were examined separately.
Four extensive reviews concluded that supervised exercise is beneficial in the treatment of CLBP and can be considered the modality of choice. These reviews compared supervised exercise with other treatments including home exercise, spinal manipulation, general stabilization and strengthening, and with no treatment at all. When supervised exercise therapy is tailored for an individual, including specific stretching and strengthening, the best outcomes are achieved.
Further support for exercise included a randomized control trial that measured pain, disability, medication use, overall improvement, and satisfaction after a 12-week treatment phase and again at 52 weeks. Supervised exercise was found to be more effective on those measurements when compared with spinal manipulation and home exercise on patient-reported outcomes.
The American College of Physicians and the American Pain Society, which have created joint practice guidelines for the overall management of CLBP, investigated numerous interventions and have made recommendations for different treatment strategies.
• Exercise therapy was given a higher recommendation than opioids in the treatment of CLBP and was recommended as a first-line treatment because of the low risks of injury and other side effects associated with exercise.
• When CLBP is sub-grouped into various treatment categories using manual therapy, trunk coordination, strengthening, endurance, and repeated movement in a specific direction, there is high-quality evidence for good treatment outcomes.
Two reviews investigated the effectiveness of opioids compared with other pharmacologic interventions and with a placebo for treating CLBP. Opioids appear to offer more relief than a placebo, but this effect is small in improving function, and participants reported an exacerbation of symptoms after discontinuing the medication. This review also reported side effects with the use of opioids, including headaches and nausea.
In another study, patients with CLBP who took narcotics within the past 30 days reported greater disability and higher pain severity scores compared with those patients not taking narcotics.
The joint practice by the American College of Physicians and the American Pain Society determined that opioids have “fair evidence for use” with CLBP when compared with trials of opioids on other chronic conditions. However, their guidelines established that opioids should be restricted to short-term use after first-line therapies fail and only when patients experience disabling pain.
To date, there are no randomized control trials for the safety and effectiveness of long-term opioid therapy for CLBP. Evidence supports the use of physical therapy, with the potential benefits generally outweighing potential risks.
Before prescribing opioids, physicians should complete a risk-benefit analysis. Providers should recognize that current evidence does not show that opioid treatment is beneficial, specifically beyond 16 weeks.
Gladkowski, C., et al. “Opioids versus physical therapy for management of chronic back pain.” The Journal of Nurse Practitioners. 2014; 10(8): 552-559.