The use of opioid medications and musculoskeletal pain sometimes go hand in hand. I have been treating patients with musculoskeletal disorders that are using opioids for their persistent pain for over 3 decades. I have seen appropriate short duration usage of opioid medications and inappropriate long-term usage of these drugs that has caused a great deal of problems. Most of the time the patient is able to work closely with their physician and wean themselves off the medications with proper exercise, physical therapy treatments and a proper home exercise program to facilitate improved function. From a Nevada County point of view we seem to be avoiding a great deal of these opioid epidemic issues. Our small community has a medical network that works well with informing each other on problem areas around patient issues. It is quite common to have a patient that is seen by their primary care physician (PCP) a specialist (orthopedic, neurology or physical medicine & rehabilitation) and a Physical Therapist (PT) with all professionals fully aware of the complete medical management of the patient. This doesn’t always happen in larger communities and can create gaps in consistent healthcare and inappropriate use of medications to manage pain.
As a PT I have thought that one of the reasons musculoskeletal disorders such as low back and neck pain don’t get the public health and funding needed relative to their cost burden on the healthcare system is that patients don’t die from low back pain. Well, unfortunately the time has come and people are dying from the management of musculoskeletal pain. The opioid crisis is now indicating that thousands of patients with garden-variety musculoskeletal disorders are in fact dying every year from these disorders due to the effects that stem from initial legitimate opioid prescriptions that turn into addiction.
Statistics of the Opioid Epidemic
The statistics of opioid related deaths are staggering. Drug overdose deaths in 2016 most likely exceeded 59,000, the largest annual jump ever recorded in the United States according to the New York Times. Opioid addiction has become more deadly by an influx of illicitly manufactured fentanyl, carfentanyl and other similar drugs. Drug overdoses are now the leading cause of death among Americans under 50. In the Midwest and Southern states of Ohio, Kentucky, Arkansas, Louisiana, Mississippi, Alabama the epidemic became so bad that the media reported on several sting operations through the Drug Enforcement Administration (DEA) that busted huge medical pain clinics. These were very large operations seeing hundreds of patients a week and prescribing the strongest, most expensive narcotics to almost all of their patients. The prescriptions were filled by the pharmacy, which happened to be owned by the doctors that owned the pain clinic, located across the street. The opioid epidemic has no boundaries. The abuse of opioids is happening in all walks of life, from the pharmaceutical companies, physicians, patients, drug dealers and kids. The opioid drugs that were once only found in the medical management of cancer patients are now found on the streets all across the United States in staggering numbers. Patients become addicted and then turn to the streets to get more drugs as the addictive properties of these drugs are overwhelming. The problem is that all these illicit drugs are much more potent than their predecessors. For example, carfentanyl is an elephant tranquilizer 5,000 times stronger than heroin. An amount smaller than a few grains of salt can be a lethal dose. In 2016 more than 140 people died of a carfentanyl overdose in the state of Ohio. Many of these deaths were people seeking help for musculoskeletal pain months or years prior. In some Ohio counties, deaths from heroin have virtually disappeared. Instead, people are dying from overdoes of fentanyl or carfentanyl. In Montgomery County, home to Dayton, of the 100 drug overdoes deaths recorded in January and February, only three people tested positive for heroin; 99 tested positive for fentanyl or an analogue.
A Colorado physical therapist Dr. Tim Flynn produced a moving public service announcement (PSA) in the media to warn people of the opioid epidemic and a call for all PT’s to take action on helping people with musculoskeletal pain to avoid opioid medications and use physical therapy as PT is a low cost highly effective solution for this national epidemic. This is the link to the short PSA by Dr. Tim Flynn.
In what the Associated Press (AP) describes as “a groundbreaking guideline,” the Ohio agency that overseas that state’s workers’ compensation program has rejected spinal fusion surgery and opioid prescriptions as an early response to back pain. Instead, the state now requires all workers with work-related back injuries undergo at least 60 days of nonsurgical care, including physical therapy, while avoiding opioids, before pursuing other treatments. In the report, the Ohio Bureau of Workers’ Compensation justified the move by citing research showing that spinal fusion surgery is “often ineffective,” can lead to complications, and may result in increased opioid use post surgery.
The research has provided the data that long-term use of opioids is a dangerous way to manage non-cancer end of life pain. It is very hard to make changes in behaviors based on data. Change occurs when the stakes are high and I hope that the opioid epidemic that is still happening across the United States that is causing thousands of unnecessary deaths is a big wake up call to action. We must share the data with anyone suffering from chronic pain to seek help in healthy and effective means before more people die needlessly due to the use of opioid medications. The research is strong in demonstrates effective management of musculoskeletal pain with physical therapy. Movement is medicine.