When discussing pain and the use of opioids, there are some important facts to consider:
The opioid crisis, as it’s now being called, demands action. Policymakers have called on state regulators and insurers since there is currently no national set of guidelines that can help to monitor and guide standardized prescription or usage recommendations.
Currently Medicare reimburses for a number of opioid drugs and does not have established guidelines or protocols. What is clear is that long term opioid users become increasingly “used to dosages,” and despite the death rates attributed to opioids, these patients can often function on incredibly high daily dosages. Someone new to the drug could be severely compromised or even die if initially prescribed dosages in that range.
State workers’ compensation systems (California, Washington, Utah, Texas) and the Veterans Administration currently use ACOEM, Official Disability Guidelines or ODG (evidence-based medical treatment and return to work guidelines), or their own guidelines, to authorize the use of opioids to treat the four areas of pain. There is a clear movement, though, to modify and reduce the number of prescriptions, dosages and regimen duration routinely prescribed by the mainstream medical community. ACOEM released its most recent guidelines in late 2014, ACOEM Practice Guidelines: Opioids for Treatment of Acute, Subacute, chronic and Post-Operative Pain.
Every guideline is based on MED or morphine equivalent dose. A typical morphine equivalent daily dose is 30 mg of morphine (oral) given every four to six hours which equals 120 - 180 mg of morphine per day “or its equivalent.” So if the drug being dispensed is Dilaudid, the morphine equivalent dose is 7.5 mg for every 30 mg of morphine, or an MED of 30 - 45 mg daily. Many of the treatment protocols only red-flag doses at or beyond an MED of 120 mg. The California Medical Board proposed an upper limit to flag an MED above 80 mg daily in 2014, and ODG guidelines offered the same cutoff. Currently there is consideration by the Division of Workmen’s Compensation (DWC) to lower their guidelines to flag use above an MED of 50 mg daily. Many of the organizations mentioned also want to propose new guidelines for “annual attempts to wean patients off opioids entirely.”
The Centers for Disease Control released its latest guidelines for prescribing opioids for chronic pain in March 2016. It recognizes the role that opioids play in the management of certain cases of pain, but it also recommends certain non-opioid therapies when:
- The risks of use outweigh the benefits;
- The patient wants to and is willing to do more than just mask the pain with a drug(s);
- When pain or function issues are linked to low back pain, hip or knee osteoarthritis, or fibromyalgia;
- When opioids are indeed indicated but use (dose, frequency) should be tapered as quickly as possible;
- When pain exceeds 90 days duration.
The ACOEM 2014 guidelines reflect a review of nearly 264,617 articles on pain studies, with at least 263 actual studies and 157 studies considered high or moderate quality. For each of the four pain situations there is a comprehensive and thoughtful set of guidelines that attempts to provide pain control but that also aims to avoid drug dependence. It still allows the physician to determine on an individual basis whether or not to exceed recommended maximal daily dose or a longer treatment phase. That’s because none of the studies used to generate the 2014 guidelines involved patients with chronic pain (not of cancer origin) on longer term opioid therapy. The one thing this new set of guidelines seems to support, at least by California policymakers, is placing limits on employer payments for long term use of opioids.
If you are someone suffering with severe chronic pain, that last statement likely scares you. It shouldn’t. There are a number of therapies that may have the potential to help you to either avoid taking opioids, to limit the time you are on an opioid drug regimen, or to help wean you from opioids. Experts including physiatrists and interventional pain specialists as well as allopathic and osteopathic doctors can evaluate your pain condition and create a plan that helps to limit opioid use, substituting or enhancing the use of medications with non-medicinal therapies. Physical therapy is one such option. Roughly 20 minutes of exercise equals 12 mg of oxycodone from a pain relieving capacity Too often patients don’t understand that their chronic pain is an indicator of tissue damage or tissue sensitivity — that their “pain alarm” is set too high and treating that problem with medications won’t resolve it.
I reached out to Tom Denninger, DPT, OCS, FAAOMPT, a physical therapist at ATI Physical Therapy in Greenville, South Carolina. He treats patients with chronic pain on a regular basis. Here are some of my questions and the answers he supplied:
Describe the different types of patients you see living with chronic pain
“There are individuals who have long term mechanical complaints, such as a bothered knee, who typically do really well with traditional PT (strengthening, etc.). When we talk about chronic pain, these are not typically the patients we are talking about. Central Sensitivity is a blanket term we talk about when someone has more multi-regional or complex pain (chronic low back pain, chronic neck pain, fibromyalgia, chronic fatigue syndrome, Lyme’s disease, etc.). We also have patients with complex regional pain syndrome where their presentation is very intense and unique.”
How many of your patients are on opiates (that you’re aware of)?
“Predictably, the vast majority. But what we hear time and time again is that they do not like the side effects, and for many patients they [opioids] are not effective, especially when patients have more neurogenic symptoms (radiculopathy, sciatica) or multiregional pain (chronic back and neck pain, fibromyalgia) or other complex conditions (complex regional pain syndrome, Lyme’s disease, chronic fatigue syndrome). It is rare to encounter someone with complex pain who is not on opioids.”
Mr. Denninger explained that there is often resistance to physical therapy, especially if it failed in a previous encounter with another practitioner. He offered that there has to be trust that the practitioner and the therapy will not increase the pain or hurt them in some way and when that is established the patient is usually willing to commit. He did acknowledge that there can be periods of discomfort when engaging tissues that are sore or deconditioned, but grading the exercises in a step-wise approach that takes into account central sensitivity can help to limit those circumstances.
The principal factor that needs to be assessed, he noted, is “an individual’s level of psychosocial distress (depression, anxiety, post- traumatic stress, etc.) where having a mental health provider who is trained to work with folks with complex pain can be key. It can come down to a patient’s willingness to learn about the factors underlying their pain experience and their willingness and ability to make changes in their belief structures and life.”
So a teamwork approach to the patient with chronic pain can be quite helpful. Mr. Denninger shared that he has been “very lucky to work alongside spine surgeons, pain management and rehabilitation providers where we have a consistent flow of communication. When we first started introducing patients to pain neuroscience education and cognitive behavioral therapy we were up front in educating physicians on what we were doing and why. They have been very supportive given the abundance of research supporting this approach.”
Can you describe a success story?
“One patient, a hospital greeter, suffered from chronic neck pain, jaw pain, and headaches, which had persisted for many years. She was about to lose her job due to frequent absences and was forced to go onto FMLA. She had seen multiple PTs and chiropractors who had convinced her something was wrong with her alignment, posture, etc. In truth, she was someone who had a lot going on in her life, was scared of movement and her pain, and had completely lost her independence and locus of control. We took a hands-off approach of care (no manual therapy) because she had become reliant on getting manipulated, so we helped to educate her and systematically introduce strengthening, which proved effective.To this day, I still get emails from her that she is doing great, is gainfully employed, and off all medication. She sticks in my head because she shared afterward that she was very close to suicide and that this journey saved her life!”
I also spoke by email with Julie Martin, a professor, who was able to resolve her pain issues with physical therapy, allowing for a dramatic reduction in her pain medication regimen. She had been on a six-medication regimen, extraordinarily high doses, and reduced to one medication daily. She relayed to me that she “wasn’t able to do basic daily tasks such as unloading my dishwasher or going grocery shopping. I’m a very independent person so having to ask for help with these types of things was extremely frustrating for me. Additionally, just getting through the day at work was very challenging because of the pain.”
Outcomes from a surgery she had included shoulder and neck pain and then subsequent, unrelenting back pain. She was on several pain medication regimens, had tried steroid injections and did try physical therapy, which did not result in the outcomes she had hoped for. It’s important to note that despite the challenges and poor outcomes, her third try with physical therapy (her motivation to reduce her medication regimen was quite strong) yielded success. Julie was very clear that in conjunction with the physical therapy she also had regular massages and worked with a personal trainer.
What advice would you, Julie, give to others who live with lower back pain when it comes to exploring alternative treatments?
“When you have a problem like back pain that impacts daily life, I think it’s important to give every possible option a try. I have found that it’s key to communicate with everyone giving you care. My doctor was the one who first referred me to my therapist and I continued to check in with her about my progress. My therapist gave me great advice on what kinds of stretches and exercises I should do at home and with my personal trainer. He also helped me articulate what I needed from a massage so I could communicate well with my massage therapist. I also made adjustments in my daily routine that made a huge difference, like using a standing desk. All these things worked well together, and my physical therapist was the point person for helping me to understand how each thing was contributing to my progress.”
Far too many individuals who suffer with severe and persistent chronic pain are taking overly high doses of opioid medications for prolonged periods of time. More access to personalized therapeutic prescriptions that include a range of treatments needs to be the standard “prescription” and these options need to be covered by insurance. It’s also clear that when a team of professionals work together, non-opioid chronic pain treatment outcomes can be quite positive. If we want to reduce mortality rates associated with opioid use, and limit dependence on these drugs, then patients need education and access to alternative non-opioid therapies.
Pharmacies are also getting in on the fight against the opioid epidemic. CVS announced that it will limit some opioid prescriptions to 7 days.