Physical Therapy, Acupuncture Reduce Opioid Dependence

A panel discussion at the National University of Natural Medicine (NUNM) sponsored by Oregon Health Forum considered the cultural swings for treating pain in the past 20 years to the current opioid epidemic and the fear of prescribing opioids.

More Oregonians die of drug overdoses than in car crashes, even though the number of adults living with chronic pain has held steady for the past 20 years.

To combat the overdose deaths, Oregon has adopted Centers for Disease Control (CDC) guidelines for prescribing opioids and work groups are looking at medical marijuana and other potential remedies. The Oregon Health Plan recently began paying for physical therapy and acupuncture rather than surgery for low back pain.

But physical therapy and acupuncture didn’t help Amanda Siebe cope with her complex regional pain syndrome. Siebe founded Disabled Americans 4 Change, to stop the CDC guidelines from taking effect. She fears the guidelines leave 116 million Americans who take daily opiates to function “with alcohol, street drugs and suicide” to ease chronic pain.

Rural communities often lack access to physical therapy and acupuncture, said Dr. Andrew Suchocki, medical director of the Clackamas Health Center who’s aware of an instance where a broken foot wasn’t treated with opioids because “new residents are terrified of opioids.”

“It’s easier to not start opioids than to diminish your dependence,” said Dr. John Muench, director of behavioral medicine in the Department of Family Medicine at OHSU. During the 1990s, providers came under fire for failing to do enough to treat pain and relied on research by the pharmaceutical industry that encouraged use of new opioids.

It takes just four doses of an opiate for people to develop resistance, said Dr. Kevin Wilson, a Hillsboro naturopath who teaches at NUNM.

“I see a lot of addicts in my practice. There’s tons of resources and medications to help OxyContin addicts taper off. I don’t know what to do to (taper off) heroin addicts.”

Insurance companies are partially to blame for the high incidence of prescription drugs, Wilson said, because traditional treatments such as naturopathy frequently are not covered, requiring people to pay for treatment themselves.

He believes topical cannabis is helpful as an anti-inflammation or anti-itch treatment and that practitioners who take an either-or approach to opioids or cannabis are “doing patients a disservice.”

“If you have two treatments and one has harms, I’m in favor of the one without harm,” said Dr. Paul Lewis, health officer for the Portland metropolitan area. “No one has ever died of cannabis” yet marijuana remains a Schedule 1 drug, the same as heroin.

“There is no life without pain,” cautioned Wilson, treatment should empower patients to understand their pain and manage expectations. “You may be uncomfortable but you shouldn’t stop daily living.”

Jan can be reached at [email protected].

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Comments

By Susan Bamberger, PT, DipMDT

On Weds, Aug 25 the Oregon Health Forum breakfast had an excellent panel of epidemiologists, medical directors, social workers and researchers all trying to address the very important issue of our state’s opioid crisis, which is one of the worst in the nation. Each panelist was asked specific questions, then the moderator opened up the questions to the audience.

The first woman to speak was a woman with severe persistent pain, with a very real and emotional plea for the use of long term opioid use. She told a story of her journey, which included other therapies, including physical therapy. Her comment: “I went to four years of physical therapy, and it didn’t do me a lick of good.” When I heard that, my heart dropped.

As a physical therapist, I was embarrassed. I was mad. I felt like one of my colleagues had dropped the ball in this very important role.

While I have heard this comment before, I know that there are physical therapists well prepared to work with this population. In hearing the panel, there is clearly a role these therapists can and do currently play in being an important team member in the management of persistent pain.

What role can physical therapists play in persistent pain management?

Currently, physical therapists alone serve a relatively small role with patients with persistent pain. As a member of an interdisciplinary team, though, they have the potential to help classify and direct patients to the right treatment for their pain.

Physical therapists are movement specialists. Physical therapists have the ability to classify and understand the pain in a way that they can steer the patient in a direction that will help them get the right treatment for their situation. Some patients need simply to move. Other patients may need one exercise to manage their pain. Others may need a combination of exercise and manual therapy.  Some have no business going to physical therapy until other issues are addressed. With 45 min to an hour to evaluate patients, qualified physical therapists will take that time to take a thorough history, and then use that history to conduct an examination that will give them the information they need to make a classification, which will guide treatment.

 

Do all physical therapists have this level of training?

 

Classifying pain and motivating patient to change lifelong habits is a challenging task. Here are some guidelines for finding a qualified physical therapist:

 

  1. Find a physical therapist familiar with motivational interviewing strategies. Without these skills, physical therapists run the risk of patients developing a dependence with their skills, and miss the very important piece of modifying habits to improve outcomes.
  2. Find a therapist who has spent some time learning to classify conditions versus treating based on pathoanatomical diagnosis. Steering away from pathoanatomical diagnoses tends to prove better results, as well as reduces fear for patients.
  3. Find a therapist who has the ability to educate effectively to patients with persistent pain.
  4. Finally, find a therapist, with a breadth of skills that they can utilize, but more than anything are willing to individualize their treatment based on the needs of the patient in front of them.

The key to managing the opioid crisis is to find alternative ways to manage pain. Movement, when prescribed correctly, provides significant pain relief for many patients. However, there are too many stories of patients who try to “just move” and end up feeling worse as a result. Direct your persistent patients to movement specialists who have the ability to diagnose movement problems and design an individualized plan that will get your patients back to life.