Why this topic?

It has been hard to ignore the surge in media and articles published in 2018 through professional platforms/bodies around the opioid epidemic. Whether it’s through online newsletters through the Australian Physiotherapy Association and American Physical Therapy Association, to marketing of the #ChoosePT campaign and published papers, everyone is starting to talk more and more about this topic. Curious to know more about what our suggested role is to play in this opioid epidemic, I began reading some of the latest reviews. This problem has been growing for several decades now and does not begin with our profession. Yet, our profession is being drawn into the conversation more strongly as time continues.

In many of the articles I have been reading, this debate is traced back to a highly unscientific claim published in 1980 (Porter & Jick., 1980) that the risk of opioid addiction was rare. Pharmaceutical companies took advantage of this statement and the push of opioid prescription flourished. What we know now is that opioid medication is highly addictive, sensitive to dosage and impacted by characteristics of the individual that is taking the medication. We have no choice but to step up and push back on this problem because of the astonishing number of opioid-related addictions and deaths.

"It is estimated that 15 million people worldwide are addicted to opioids, and 69 000 people die from opioid overdose each year. Only 10% of these individuals received a referral for physical therapy services, while up to 45% received an opioid prescription.” (Mistaken, Moore & Flynn., 2018, p. 350) While human deaths and medication overdose are not generally metrics that dictate our involvement in a problem, what I have come to realise is that our medical profession and the government are trying hard to trace this problem back to the original source and create an alternative trajectory path for the future of pain management. Opioids are being used as a launching platform for the transformation of our global management of chronic pain.

The APTAs involvement in responding to the opioid crisis has been active since 2015, with the launch of the #ChoosePT campaign. The association is working with 40 other organisations as the Opioid Stewardship Action Team, a group assembled by the National Quality Forum (NQF), a health care research and advocacy group. APTA is a member of NQF.

According to NQF, the goal of the team is to work on “strategies and tactics to support appropriate opioid prescribing practices and more effective pain management, particularly for individuals with chronic pain and those at risk of dependence and addiction.” That work is presented in a “playbook” that the NQF released this year. The NQF hopes this manual will help to establish a more cohesive approach to pain management. Disappointingly, that playbook is sold for $150, which creates a substantial barrier to accessibility for those (like me) trying to learn more around this topic.

There are several target messages associated with the #ChoosePT campaign designed to raise awareness on the topic.

According to the CDC, in 2012 health care providers wrote 259 million prescriptions for opioid pain medication, enough for every American adult to have their own bottle of pills. The risk for misusing prescription opioids is real.
According to the CDC, every day, over 1,000 people are treated in emergency departments for misusing prescription opioids. The risk for addiction is real.
According to the CDC, as many as 1 in 4 people who receive prescription opioids long-term for non-cancer pain in primary care settings struggles with addiction. The risk for heroin use is real.
According to the CDC, among new heroin users, about 3 out of 4 report abusing prescription opioids before using heroin. Physical therapy is a safe and effective alternative to opioids for long-term pain management.

My aim for the remainder of this blog is to clarify a little further the pharmacological side of this debate and the potential engagement of physiotherapists moving forward. These are my thoughts...

What drugs are we talking about?

In order to learn more about the basic pharmacology, I took an online course through the APA about opioid and neuropathic medication. It was very informative and helped me understand the differences between common opioid medications, their use and the common side effects.

Opioids are a mainstay of analgesia for strong pain and no opioid is superior to any other but some may be better than others for certain patients.
With Opioids there is no standard dose! Therefore you have to start low and then increase until you effectively control pain without side effects.
Most common factor for determining dose of opioids is age not weight.

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Side effects (general systemic & dose related) (Brooks, et al., 2016, p.85-86):

CNS - drowsiness, confusion, mood changes, hallucinations, and miosis
Respiratory - slowed respiratory rate
GI - constipation, nausea, vomiting, and urinary retention
Cardiovascular - hypotension, increased risk for myocardial infarction and QT prolongation
Endocrine & immune - decrease testosterone levels, leading to hypogonadism, sexual dysfunction, infertility

“Opioid analgesic efficacy often declines with continuous use because of the adaptations of dependence and tolerance, theoretically producing a state of continuous withdrawal. This may not be true if opioids are taken intermittently” (Ballantyne., 2017, p.1775)

There are other serious long term consequences associated with the use of opioids that we are becoming aware of in pre-clinical trials, which are associated with changes in our neuro-immune modulation. The first is opioid tolerance that can lead to cravings and overdose. "Opioid tolerance is characterized by reduced sensitivity to an opioid agonist, and is usually manifested by the need to escalate doses to achieve the desired effect” (Grace, Maier & Watkins., 2015, p.4).

The second is that opioids have an impact systemically on our immune system that may paradoxically increase pain sensitivity rather that than reduce it! This is called opioid induced hyperalgesia, which actually makes the pain worse. "Opioid-induced hyperalgesia is a paradoxical increase in pain sensitivity that develops after short- and/or long-term opioid exposure. The neuroimmune hypothesis of opioid-induced hyperalgesia asserts that opioid induction of immune mediators in the CNS not only neutralizes anti-nociception (manifesting as tolerance, described above), but actually induces nociception. Accordingly, blockade of glial reactivity, their pro-inflammatory products, or stimulating anti-inflammatory mechanisms after repeated morphine administration attenuates ensuing nociceptive hypersensitivity.” (Grace, Maier & Watkins., 2015, p.7).

What role are we meant to play?

A recent article published in the JOSPT (Mistaken, Moore & Flynn., 2018) presents a viewpoint about the role of Physical Therapists in the Opioid Epidemic. As they explain, at the turn of the century there was a CPG published that included ‘pain’ as a 5th vital sign and encouraged physicians to include the questioning of pain. However, this persistent focus on pain needs to be re-examined because it cannot be as easily and reliably measured at the same objective level as heart rate and blood pressure for example (Mistaken, Moore & Flynn., 2018, p. 351).

What these authors, and many others have proposed, is that Physical Therapists have a unique position to discuss safe, evidence-based alternative to opiods for managing pain as well as promoting wellness. In order to achieve this, we need to shift the focus of treatment from eliminating pain completely, to minimizing the impact of pain on quality of life (Wenger, et al., 2018). Pain relief is much more than reducing the intensity of the sensory experience.

It involves changing the affective impact of the experience and the subsequent functional impact on someone’s life (Manhapra, Arias & Ballantyne., 2017). I think this is a key component of pain management that we play a role in. Patient’s will share their pain experience with us and more importantly, we will evaluate the effectiveness of physical therapy treatments by understanding how such treatments have changed the way in which pain is impacting their life.

Personally, I can see two possible scenarios occurring as a result of patients being recommended to try PT first.

The first is to alter the way we assess acute pain and refer for physical therapy services. More specifically how we channel the newly injured, acute pain patient towards non-drug treatments. In this scenario, Physiotherapists are well placed to assess the multidimensional presentation of pain, educate patients about available treatments and guide them through rehabilitation.
The second scenario is far more complicated as it involves capturing those who were previously prescribed opioids due to old standards of care or first-line treatment that were never adjusted, and take them through a tapering process to reduce their current usage. This opioid tapering process requires the involvement of an interdisciplinary team and pain specialists to safely and effectively alter drug use. While Physiotherapists are still able to provide pain education and functional rehabilitation programs, there is a large component of treatment which involves directly changing drug use and opioid tapering is complicated. My fear is that most Physios don’t actually know anything about the opioid tapering process and would not be able to manage such a patient in a 1:1 environment. The patients described in this scenario would benefit more greatly from referral to a chronic pain clinic.

Chronic pain clinics often involve (Wenger, et al., 2018, p. 425):

100 hours of therapy
Inpatient rehab setting
4-8 hours per day, 5 days per week, 3-4 weeks
These intensive demands aren’t suitable for the 1:1 private practice setting and need to be completed in a dedicated environment with a specifically trained team.

Ultimately, Physiotherapy can’t tackle this problem independently of other professions and nor has it been suggested we do so. Wegner, et al (2018) provide an outline of the key pillars that they believe will lead to achieving the ultimate goal, where the patient is self-managing with little or no opioid usage with the support of an interdisciplinary team. These ideas have been summarised below.

Public Health: In 2016 there was a new CPG published with recommendations for the prescription of opioids for patients with chronic pain.
Clinical knowledge
1. Practitioner knowledge about the use of opiods, side effects, risks and signs of misuse.
2. Incorporation of new knowledge about opioid induced hyperalgesia and the immune system.
3. Awareness of the complex process of opioid tapering.
Neuroscience: Practitioner knowledge about the neuroplastic changes that occur in chronic pain and changes in EBP for chronic pain.
Education: Providing the patient with pain neuroscience education.
Wellness: Providing patients with knowledge around safe exercise to maintain their fitness and the positive impacts of exercise on recovery. Exercise helps us access the drug cabinet in our brains!
Mental health: Identifying psychological factors that impact recovery - kinesiophobia, depression, anxiety, motivation, catastrophization.
Patient characteristics: Obtaining a thorough history of the patient's pain story and engaging them as an active participant in their care.

As part of this process to providing more unified pain-management care, our priorities for further research and professional upscaling should include (George & Greenspan., 2018, p.287):

Gaining an improved understanding of how acute pain transitions to a chronic condition
Ensuring better access to frontline, nonpharmacological treatments
Developing viable means of fostering self-management of chronic pain
Advancing routine clinical implementation of effective strategies

Devan and colleagues (2018) discuss the following enablers and barriers to successfully achieving self-management of chronic pain, which fit neatly with the priorities identified above and the goals for treatment from Wegner et al (2018).

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In summary

Physiotherapists are being prepped that we should be ready to step into the conversation around opioid addiction, side effects and that patients will hopefully be referred to our services in the future as a non-medicated strategy for pain management. “We must continue to be purposeful and deliberate in pursuit of evidence that supports best practices for nonpharmacological pain management” (George & Greenspan., 2018, p.288).

To stop the prescription of opioids as a first-line treatment for pain is one step forward in the right direction, but, to successfully taper the use of long term opioids is a far more complicated challenge. After reading several articles on opioid addiction and taping, CPGs ect, I realise just how far out of my depth I am to deal with this secondary situation in the opioid epidemic without the support of other professionals.

It certainly has left me wondering...

Is our knowledge base deep enough?
Is our professional identity strong enough?
Are we ready to present a united front against the opioid epidemic?
Are our approaches to the management of chronic pain consolidated enough to create this world-wide shift in thinking and produce a positive result?

Sian

References

Ballantyne, J. C. (2017). Opioids for the Treatment of Chronic Pain: Mistakes Made, Lessons Learned, and Future Directions. Anesthesia & Analgesia, 125(5), 1769-1778.

Berna, C., Kulich, R. J., & Rathmell, J. P. (2015, June). Tapering long-term opioid therapy in chronic noncancer pain: Evidence and recommendations for everyday practice. In Mayo Clinic Proceedings (Vol. 90, No. 6, pp. 828-842). Elsevier.

Brooks, A., Kominek, C., Pham, T. C., & Fudin, J. (2016). Exploring the use of chronic opioid therapy for chronic pain: when, how, and for whom?. Medical Clinics, 100(1), 81-102.

Chimenti, R. L., Frey-Law, L. A., & Sluka, K. A. (2018). A Mechanism-Based Approach to Physical Therapist Management of Pain. Physical therapy, 98(5), 302-314.

Devan, H., Hale, L., Hempel, D., Saipe, B., & Perry, M. A. (2018). What Works and Does Not Work in a Self-Management Intervention for People With Chronic Pain? Qualitative Systematic Review and Meta-Synthesis. Physical therapy, 98(5), 381-397.

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. Jama, 315(15), 1624-1645.

George, S. Z., & Greenspan, A. I. (2018). Nonpharmacological Management of Pain: Convergence in Priorities Fuels the Drive for More Evidence.

Grace, P. M., Maier, S. F., & Watkins, L. R. (2015). Opioid‐Induced Central Immune Signaling: Implications for Opioid Analgesia. Headache: The Journal of Head and Face Pain, 55(4), 475-489.

Leung, P. T., Macdonald, E. M., Stanbrook, M. B., Dhalla, I. A., & Juurlink, D. N. (2017). A 1980 letter on the risk of opioid addiction. New England Journal of Medicine, 376(22), 2194-2195.

Manhapra, A., Arias, A. J., & Ballantyne, J. C. (2017). The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary. Substance abuse, 1-10.

Mintken, P. E., Moore, J. R., & Flynn, T. W. (2018). Physical Therapists’ Role in Solving the Opioid Epidemic. journal of orthopaedic & sports physical therapy, 48(5), 349-353.

Porter, J., & Jick, H. (1980). Addiction rare in patients treated with narcotics. The New England journal of medicine, 302(2), 123.

Wenger, S., Drott, J., Fillipo, R., Findlay, A., Genung, A., Heiden, J., & Bradt, J. (2018). Reducing opioid use for patients with chronic pain: an evidence-based perspective. Physical therapy, 98(5), 424-433.

Online links:
https://noijam.com/2018/06/13/morphine-madness/