There’s solid evidence that physical therapy as a first-line approach for low back pain (LBP) improves outcomes, but not many studies have focused on the factors that are associated with referral to physical therapy in the first place, regardless of later participation in treatment. Now authors of a recent study believe they’ve found associations indicating that the very act of referral for physical therapy may point to the ways a primary care provider’s approach to LBP can affect patient perceptions and reduce odds of later opioid use, even when the patient doesn’t follow through with the referral.
The study, published in the Journal of the American Board of Family Medicine looked at data from 454 Medicaid enrollees who were initially treated by a primary care provider for LBP, of which 215 received a referral for physical therapy. While researchers were interested in differences between the referral and nonreferral groups, the target of their study was something they believe is missing in current research: an examination of the entire referral population, regardless of whether those patients followed up with actual physical therapy.
As a 19-year player in the National Basketball Association (NBA), Grant Hill was no stranger to injury, both major and minor. Experiencing “aches and pains, bumps and bruises is kind of par for the course,” he says.
Now available from APTA’s Move Forward Radio: a conversation with Hill, who describes his experience with injury, managing pain, and what he would do differently today. “We all have pain in some fashion. The most important thing is to educate yourself…about pain—how do you handle postsurgery? What are your rights as a patient?” With regard to opioids, he explains, “You have options.”
The 7-time all-star retired in 2013 after numerous ankle injuries and surgeries—and painful recoveries—over the course of his career. Hill is a strong proponent of nonopioid alternatives to pain management and is a spokesperson for Plan Against Pain, a national campaign that educates the public on the availability of nondrug approaches to pain treatment postsurgery. As a player, he was prescribed opioids after surgery and for very painful injuries but says, “I didn’t like the way I felt.” Hill tried to find alternative ways to treat his pain, including physical therapy. “Physical therapy has been an integral part of my career and my longevity” as a player, he says.
The recommendations contained in a new National Academies of Sciences, Engineering, and Medicine (National Academies) report on pain management and the opioid crisis are wide-ranging, but a few may sound familiar to physical therapists (PTs), physical therapist assistants (PTAs), and anyone familiar with APTA’s #ChoosePT campaign—namely, the need to support nonpharmacologic approaches to pain treatment through better reimbursement models, and the necessity of continued efforts to educate the public on effective alternatives to opioids.
The positions on reimbursement and public education were among 21 recommendations included in the National Academies’ report titled “Pain Management and the Opioid Epidemic,” a comprehensive document that examines the opioid crisis from multiple perspectives. The overarching theme of the report: if America is serious about solving the opioid crisis, it’s going to require work and change at nearly every level of health care, public policy, and even clinical education.
The latest news on the opioid crisis is decidedly mixed. Reports show some reduction in prescription rates and dosages, but an overall increase in prescription length, wide variation in prescribing across the US, and prescription prevalence in 2015 that was 3 times as high as it was in 1999 and 4 times higher than in Europe in 2015. CDC Acting Director Anne Schuchat told National Public Radio that the 2015 per capita prescription opioid rates are enough for “every American [to] be medicated around the clock for 3 weeks.”
The analysis, from the US Centers from Disease Control and Prevention (CDC), came on the heels of another report from the Agency for Healthcare Quality and Research (AHRQ) showing that opioid-related inpatient stays and emergency department (ED) visits more than doubled between 2005 and 2014.
When it comes to rehabilitation of individuals with nontraumatic knee pain (NTKP), authors of a new study concluded that it really is a case of “the sooner the better”—at least when it comes to reducing use of drugs, injection therapies, and surgeries later on.
In a retrospective cohort study that analyzed records of 52,504 Medicare beneficiaries, researchers from the University of Pittsburgh found that patients with NTKP who received rehabilitation within the first 15 days after diagnosis were 33% less likely to use narcotic analgesics over the following year than patients who received delayed or no rehabilitation. Additionally, the early rehabilitation group was 50% less likely to move to nonsurgical invasive procedures such as corticosteroid injections, and 42% less likely to undergo later knee surgery. Results were published in Physical Therapy (PTJ) APTA’s scientific journal.
Although awareness of the severity of the nation’s opioid crisis is growing and the number of practice guidelines recommending nondrug approaches to pain treatment is increasing, the problem itself continues to take its toll on Americans across the country. That toll is well-documented by the media, with an increasing amount of attention also being paid to how the country found itself in this situation and what we do to make our way out of it.
Here’s a brief roundup of recent reports.
Despite guidelines, Americans are still receiving lots of opioids for low back pain.
A National Public Radio – Truven survey reveals that more than half of respondents experienced low back pain in the last year; among those who sought help from a physician, a surprisingly high number received prescriptions for painkillers. “We have a serious problem with our health care delivery system where physicians are highly incentivized to prescribe pills and perform procedures because that’s what pays,” Stanford University psychiatrist Anna Lembke tells NPR. “They’re also motivated to please patients but don’t have much time to manage complex medical conditions.”
The opioid epidemic knows no borders, and neither should the physical therapy profession’s response to it: that’s the concept at the heart of a new collaboration between APTA and Canadian Physiotherapy Association (CPA).
The associations’ “shared commitment” was laid out today in a statement that describes both organizations as devoted to “helping Americans and Canadians find healthier ways to manage pain and reduce the use of prescription pain medications.”
The United States is in the midst of a costly and deadly opioid epidemic. There are no easy answers to this problem, but physical therapists could be a big part of the solution. Physical therapy’s potential for effective pain management has already been recognized by a Centers for Disease Control and Prevention (CDC) initiative indicating that physical therapy should be a front line option for patients with chronic pain conditions. In response, APTA initiated the #ChoosePT campaign to let patients and providers know that physical therapists are a viable early option for pain management.
These are exciting developments, and they bring new opportunities and challenges to our profession. The opportunity is clear: a move away from widespread opioid use could allow more patients with pain to benefit from physical therapy, which offers pain relief that is effective and does not carry the risks associated with opioid use.
The #ChoosePT campaign is helping to call attention to the role physical therapists (PTs) and physical therapist assistants (PTAs) can play in providing consumers with effective, nondrug approaches to pain management.
But winning the battle against opioid abuse will take more than raising awareness—it will also require real change.
Much of that change has to happen around the ways everyone—providers, payers, and patients—view pain and its treatment, but those changes could happen more quickly if a few policies were brought up to speed in ways that would make it easier for the public to access and afford sufficient physical therapy. With improved access comes improved understanding of the real, safe alternative PTs and PTAs offer.
Physicians across the United States can expect something in their mailboxes soon—a letter from the Office of the US Surgeon General urging them to take part in the battle against the opioid epidemic, accompanied by a card that specifically mentions physical therapy as one of the preferred first-line approaches for treatment of chronic pain.
“Everywhere I travel, I see communities devastated by opioid overdoses,” writes Surgeon General Vivek Murthy, MD. “I meet families too ashamed to seek treatment for addiction. And I will never forget my own patient whose opioid use disorder began with a course of morphine after a routine procedure.”
In the letter, Murthy asks physicians to sign a pledge at www.TurnTheTideRx.org, the surgeon general’s initiative to stem the opioid abuse epidemic.