Let’s Not Swing the Opioid Pendulum Too Far | Modern Manual Therapy Blog

Let’s Not Swing the Opioid Pendulum Too Far

The opioid epidemic is a major issue here in the US. In March of this year the FDA released new safety labeling on immediate release opioid pain medication. The CDC has also put out new guidelines for prescribing opioids for chronic pain. In July, HHS back by the President put out a press release about the epidemic covering items that were in their March 2015 HHS Opioid Initiative. All of this work is helping put continued weight behind the need to get this major health issue under control.

“The opioid epidemic is one of the most pressing public health issues in the United States. More Americans now die from drug overdoses than car crashes, and these overdoses have hit families from every walk of life and across our entire nation,” said Secretary Burwell.

The APTA quickly, and rightly in my opinion, jumped in to help transform society to play an important role in the opioid epidemic. The release of the #ChoosePT campaign is timely and vital to help with this public health issue .Physical therapy can be helpful for individuals with chronic pain when delivered in the context of a comprehensive biopsychosocial program. The therapist must have a sound understanding of the complexities of pain; seeing it and treating it beyond just a symptom from the tissues or brain. For PT to be the most beneficial for the person in pain, the therapist has to understand pain is part of an embodied conscious experience. We have to treat it based on top-down and bottom-up EBP interventions. The person as a whole, not their tissues, needs to be considered and cared for through shared decision making.

I will say I am a bit concerned that we may accidentally swing our pendulums too far as the above picture could suggest to some if they don’t understand the details. It could be seen as an “either/or” when it comes to opioids and PT, when many times it should be an “and” when considering opioids and PT to assist in treating a person in pain.

There is no question that in many cases opioids have been used inappropriately (prescribed too much or too little, given at too high or too low of a dose) for many individuals suffering with pain. But, it is also a very effective drug for many people in pain. Opioids help reduce acute nociception and can potentially reduce the risk of developing chronic pain for those in the more acute phase. They can also be an effective part of a comprehensive chronic pain treatment for some. My hope is that those of us in the physical therapy profession educate ourselves properly and understand how to talk to our patients about the use of opioids, because they will ask us.

The use of opioid medication is very different when using it for acute/nociceptive pain compared to more chronic pain. The use of opioids in the acute situation may be very valuable in reducing acute pain thus helping with the war on chronic pain. Many studies have linked higher levels of acute pain to increased development of chronic pain. As often stated: “the best way to treat chronic pain is to prevent pain in the first place”. Opioids can be an effective part of a prevention plan with acute pain. The significant biological, psychological and social changes that occur as pain persists can be very hard to overcome, so not letting that happen is important.

In chronic pain the use of opioids gets a bit trickier. We know some individuals can get opioid induced hyperalgesia. This is when the opioid prescription is actually making the individual more sensitive. This does not occur with everyone, many individuals can be treated with long term opioid use and have no significant ill-side effects. They are helped tremendously by using the medication as part of a comprehensive pain treatment program. How opioids work with different individuals seems to have a large genetic component. This is based on how the drug reacts and works with various receptors in that individual. Significant research is being done to find which individual genotype(s) will respond to different opioids and the proper dosing based on someone’s genotype. Some individuals don’t actually have a ceiling effect with opioids either. The dose can get very high and they still will have no ill effects and actually do better because of the changes in their tolerance to the medication over time.

We need to make sure that the message we deliver to patients and the public is not one that “opioids are bad”. Instead “improper use of opioids is bad”. Many times opioids can and should be a part of a comprehensive multidisciplinary biopsychosocial plan to help those with pain. Let’s make sure we don’t let this pendulum swing too far. We don’t want to actually harm some people that benefit from opioids, while we are helping reduce opioid use in those that are not benefiting.

via Dr. Kory Zimney, DPT

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

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