APTA’s #ChoosePT opioid awareness campaign makes the case that opioids simply “mask” pain—but a new study in JAMA has concluded that the drugs probably don’t even do that much, at least not any more effectively than nonopioid medications. The research, which focused on individuals with chronic back pain or hip or knee osteoarthritis (OA) pain, led authors to an unequivocal conclusion: there’s no support for opioid therapy for moderate-to-severe cases of those types of pain.
The published findings are based on a study of 240 randomized patients in the Minneapolis, Minnesota, Veterans Affairs (VA) health care system who reported chronic back pain or knee or hip OA pain, defined as daily moderate-to-severe pain for 6 months or more with no relief provided by analgesic use. Participants were divided into 2 groups: 1 that received an opioid regimen, and a second group that received nonopioid drugs.
To more closely resemble real-world treatment, researchers used a “treat-to-target” approach that stepped up the drugs as needed for participants to reach identified goals. The opioid regimen began with immediate-release morphine, hydrocodone/acetaminophen, and oxycodone, but the regimen could advance to sustained-action morphine and oxycodone, and on to transdermal fentanyl. The nonopioid approach began with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS), but it could move on to topical analgesics and finally to drugs requiring prior authorization (such as pregabalin and duloxetine), including tramadol. All participants also were permitted to pursue nondrug treatment during the study, but researchers did not evaluate data related to those treatments.
Each year, more than 300 patients with chronic pain take part in a three-week program at the Pain Rehabilitation Center at Mayo Clinic in Rochester, Minn. Their complaints range widely, from specific problems such as intractable lower-back pain to systemic issues such as fibromyalgia. By the time patients enroll, many have tried just about everything to get their chronic pain under control. Half are taking opioids.
But in this 40-year-old program, they can’t stay on them. Participants must agree to taper off pain medications during their time at Mayo.
Still, more than 80 percent of the patients who enroll remain through the entire program, says Wesley Gilliam, the center’s clinical director. And many previous opioid users who finish the treatment report six months later that they have been able to stay off those drugs. Just as important, he adds, they have learned strategies to deal with their pain.
Authors of a new study have found that for patients with low back pain (LBP), the presence of comorbidities such as diabetes, mental health issues, and hypertension raises the risk that they’ll receive LBP care that uses more resources and veers off-course from LBP guidelines—including more prescriptions for opioids.
The study, published in the Journal of Evaluation in Clinical Practice, analyzes commercial insurance claims data from 2007 to 2011 involving 513,980 adults with new visits for back pain. Researchers tracked LBP care-related claims for 3 years after the initial visit as well as procedure use and treatment patterns for the first 42 days after the visit, and matched these data with patients identified as having 0, 1, or 2 or more comorbidities based on ICD-9 codes. APTA member Sean Rundell, PT, DPT, PhD, was lead author of the study.
There was plenty to blame: the car wreck that broke his back. The job pouring concrete that shattered his spine a second time. The way he tore up his insides with cigarettes, booze, cocaine, and opioids.
It all amounted to this: Carl White was in pain. All the time. And nothing helped — not the multiple surgeries, nor the self-medication, not the wife and daughter who supported him and relied on him.
Then White enrolled in a pain management clinic that taught him some of his physical torment was in his head — and he could train his brain to control it. It’s a philosophy that dates back decades, to the 1970s or even earlier. It fell out of vogue when new generations of potent pain pills came on the market; they were cheaper, worked faster, felt more modern.
Add the Canadian Medical Association to the list of organizations shifting guidelines away from opioids in the treatment of chronic noncancer pain. In a set of updated recommendations that authors describe as consistent with US Centers for Disease Control and Prevention (CDC) guidelines, Canadian physicians are being urged to pursue nonopioid and nondrug treatments as a firstline approach.
The guidelines, published in the May 8 edition of CMAJ, are an update to opioid prescription guidelines released in 2010, in which “almost all supported the prescribing of opioids,” according to the new guidelines’ authors. The new recommendations take a markedly different position, advocating not just for nondrug approaches but also for lower dosages when opioids must be used, as well as for tapering programs for patients receiving high-dosage therapy of 90 milligrams or more daily.
Taking a pill to ease chronic pain is easy, at least at first. But it comes with side effects – the most well-known of which is probably addiction. One alternative to opioids for chronic pain is physical therapy.
“Side effects of physical therapy are less pain, improved movement, improved function,” said Carrie Abraham, president of the West Virginia Physical Therapy Association. “So they’re all positive side effects versus with the opioids we have those negative side effects of dependency and addiction.” Abraham is one of almost 1,500 active physical therapists in West Virginia. She said although there isn’t exactly a lack of physical therapists in West Virginia, transportation can still be an issue. West Virginia is highly rural after all. But the bigger issue is insurance coverage.
“Now we have insurance companies that are limiting access to physical therapy care,” she said. “They’re limiting the number of visits directly in some cases, but then they also are limiting access by the amount of copay and coinsurance that patients are required to pay. So depending on their financial status they might not be able to afford to attend physical therapy visits multiple days a week.”
Current orthopedic surgeon guidelines recommend use of physical therapy, tramadol, and NSAIDs for nonsurgical treatment of knee OA, and against use of injections and opioids other than tramadol.
Analysis of claims utilization data found that the top 3 interventions were corticosteroid injections (46.0%), hyaluronic acid injections (18.0%), and opioids other than tramadol (15.5%), none of which are recommended in the guidelines.
Physical therapy was prescribed for only 13.6% patients.
Adhering to AAOS treatment guidelines for knee OA could decrease cost of care by 45%.
If health care providers treated patients with knee osteoarthritis (OA) according to established guidelines that include physical therapy, researchers say costs of treatment could drop by as much as 45%. Yet too many physicians are prescribing interventions that are not supported by evidence and may even carry extra risk.
Two researchers believe that when it comes to pain treatment, if the US truly wants to alter the future, it could do well to look to the preopioid past—and then make policy changes that would increase patient access to nondrug approaches to chronic pain.
In a recent opinion piece published in US News and World Report, authors Jason Doctor, director of health informatics at the USC Leonard D. Schaeffer Center for Health Policy and Economics, and Joan Broderick, senior behavioral scientist at the University of Southern California Center for Economic and Social Research, write about the ways pain treatment should change in light of the Comprehensive Addiction and Recovery Act passed by Congress earlier this year. That act, aimed at battling the opioid abuse epidemic, includes the establishment of a Department of Health and Human Services task force that will review and modify best practices for pain management.
Andre Machado, MD, chairman of the Neurological Institute at Cleveland Clinic, thinks opioids are remarkable.
“But ‘remarkable’ can have 2 meanings,” he says. “It can be a positive remarkable, or a negative remarkable. And the long-term use of opioids, when we use it chronically, is often remarkable in the wrong direction.”
Now available from APTA’s Move Forward Radio: a conversation with Machado, who is leading an innovative pain treatment research project that puts a combination of physical therapy and behavioral therapy at the front lines of pain treatment, and takes a cautious approach to the use of opioids. Machado shared his thoughts on opioids and the need for a cultural shift on attitudes about pain in a recent TIME magazine opinion piece. His Move Forward Radio interview delves even deeper into his beliefs on what constitutes truly effective pain treatment.