The Opioid Epidemic

1. The Opioid Epidemic By. Alex Radjen

2. Background1 • - Pain has been described in the medical literature as a “uniquely individual and subjective experience” and “among the most controversial and complex” medical conditions to manage • - Initially started 3 decades ago as pain was being “undertreated” • Pain became a 5th vital sign - Pain was seen as a primary condition, rather than a consequence of disease or injury • This gave the pharmaceutical companies a marketing opportunity to advertise their products as a way to provide rapid and long-term pain relief - In 2016, the CDC issued a guideline for prescribing opioids • 42,000 people in the United States died from an opioid overdose • 17,000 whose deaths were attributed to prescription opioid overdoses. • The guidelines addressed: • When to initiate or continue opioids for chronic pain • Opioid selection, dosage, duration, follow-up and discontinuation • Assessing risk and addressing harms of opioid use • -

3. #ChoosePT • In 2016, the APTA launched the #choosePT campaign to educate consumers on the opioid epidemic and to choose physical therapy as a source of pain management • Online advertisements, TV and radio public service announcements, and other targeted advertising and media outreach

4. APTA White Paper statement: June 20181 • - "Moving forward, the health care system must reexamine its approach to pain, including how causal factors are identified, what tools or measures are used to quantify its impact, and how the approach to treatment is aligned with the patient’s goals and values” • - Paper Content: • history of the use of opioids in pain treatment, an examination of concepts around pain, and case scenarios that demonstrate how treatment by a physical therapist (PT) can help patients reduce or eliminate opioid use

5. The Numbers1 • - Sales of prescription painkillers to pharmacies and providers had increased 300% since 1999. • - In 2010, 12 million people ages 12 and older reported using prescription painkillers “non-medically.” • - In 2011, more than 40 people were dying each day from overdoses involving prescription opioids. • - In 2017, 9 out of every 10 Americans who are at least 60 years old say they have taken at least 1 prescription drug • - Children in the United States are 3 times more likely to be prescribed antidepressants as children in Europe are.

6. Techniques Pt’s can use to help manage pain1 • Exercise • Studies have shown that people who exercise regularly experience less pain • Manual Therapy • hands-on manipulation of joints and soft tissue to modulate pain, reduce swelling and inflammation, and improve mobility • Stress Management • Interventions such as mindfulness, relaxation, visualization, and graded exposure to stress-producing items • Sleep Hygiene • sleep deprivation can increase sensitivity levels and contribute to increased stress and pain • Pain Neuroscience Education • Individuals who don’t understand the mechanisms and contributors to their pain may be more likely to seek pharmacological treatment for that pain

7. Pain Neuroscience education2 • - Chronic pain involves changes in the central nervous system that perpetuate persistent pain • - Definition • A form of cognitive behavioral therapy that is aimed to increase the patient’s knowledge and understanding of pain, in order to reduce the fear that is commonly associated with musculoskeletal injury • Goal: Combined information of the neurobiology of pain with physiology of nervous system in easy to understand pictures, examples, metaphors

8. Functional Mri2 • Row 1: Patient at resting position • Row 2: Patient asked to do a posterior pelvic tilt/ abdominal brace • Row 3: Patient asked to do a posterior pelvic tilt/abdominal brace post PNE

9. 3 Major implications in Physical Therapy • Behavior Change • Hands-On or Hands-Off Approach • Physical Therapy Research for PNE Benefits

10. 1) Behavior Change • - Terminology used • - Imaging

11. 1) Behavior Change: terminology 2 • - Biomechanical and anatomical  neurobiology & psychosocial • “Back Schools” • Teaches patients about structure and function of spine, and proper body mechanics for lifting and other activities • Limited Effectiveness: no pain processing, no neuroscience, no psychosocial • Determinants of long-term disability and chronic pain

12. 1) Behavior Change: imaging 3 • - Advanced Imaging is commonly used in the evaluation of individuals with LBP • Findings: disc degeneration, disc height loss, disc bulge, disc protrusion, annular fissures, facet degeneration, and spondylolisthesis • - Normal age related change rather than pathologic process • Degenerative findings not necessarily associated with the degree or presence of LBP • - Patients describe their pain in mechanical terms • ” my sciatic nerve is trapped”, “ I have a slipped disc”, “discs are shrinking” • Language of the radiologists/physicians is reflected by the patients • Focus on repair not damage

13. 2) Hands On- Hands off Approach: Is education just enough? 4 • - PNE with a combination of therapeutic exercise or manual therapy is much more superior and effective than solely doing PNE for pain reduction • - Combined manual therapy, specific exercise, and PNE is most effective in producing functional and symptomatic improvements in individuals with chronic LBP

14. Physical Therapy Research 5 • - PNE warrants continued investigation and research from scientists and clinicians to understand the effects that this has on behavioral change • - Evidence supports PNE, but researchers must provide clinically relevant findings to translate into evidence based practice • - PNE has shown to be effective, and more research is needed to change patients and clinicians outlook • Invaluable  Valuable • - Need for a new outcome measure? • Pain scale  measures pain, not behavioral change

15. Acute Pt in pain management6 Help prevent neuroplastic changes by aggressively treating acute pain during hospitalization: • Early mobilization • Include pain management in discharge planning • Patient’s confide their anxieties, depression, or history of substance abuse.  Risk factors of opioid abuse that can be communicated to the healthcare team

16. Questions?

17. Resources • 1)American Physical Therapy Association.  Beyond opioids: How physical therapy can transform pain management to improve health  . 2018:1-15. • 2)Louw, A., Puentedura, E. “., & Mintken, P. (2012). Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: A case report. Physiotherapy Theory and Practice, 28(1), 50-62. 10.3109/09593985.2011.562602 • 3) Brinjikji et al. (2014) Brinjikji W, Luetmer P, Comstock B, Bresnahan B, Chen L, Deyo R, Halabi S, Turner J, Avins A, James K. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology. 2014;36:811–816. doi: 10.3174/ajnr.A4173. • 4) Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4):297–302. • 5) Louw A., Puentedura E.J., Zimney K., Schmidt S. Know Pain, Know Gain? A Perspective on Pain Neuroscience Education in Physical Therapy. J. Orthop. Sports Phys. Ther. 2016;46:131–134. doi: 10.2519/jospt.2016.0602. • 6) Kim Levenhagen. Acute therapists play a role in the fight against opioid addiction. Academy of Acute Care Physical Therapy. • 7) Google