Physician Anxiety and the Opioid Crisis

by Sudeep Mehta, MD

The chemical structure of hydrocodone.

The recent opioid epidemic has left physicians in a state of anxiety. The introduction of the STOP Act has led physicians to be cautious when prescribing opiates due to the fear of inducing long-term opiate addiction and dependence. It is imperative as physiatrists for us to still address pain management with a holistic and evidence-based approach, with a confident approach to ultimately achieve optimal return of function to their pre-morbid state.

An article in the JAMA Network journal in April, 2019 entitled “Association Between Opioid Dose Variability and Opioid Overdose Among Adults Prescribed Long-term Opioid Therapy,” discusses the correlation of opioid dose variability with the risk of overdose. A nested case-control study using a Colorado integrated health plan in the duration of 2006 to 2018, studied dose variability in >14,000 patients who were prescribed long-term opioid therapy. A dose-response association between variability in opioid dose and overdose risk was noted, and sustained opioid therapy discontinuation was associated with an approximate 50% reduction in risk of over-dose. Awareness of this issue is essential to minimize frequent medication adjustments and optimize other modalities when addressing low back pain.

A systematic review entitled “The Effect of Timing of Physical Therapy for Acute Low Back Pain on Health Services Utilization: A Systematic Review” in 2019 reviewed eleven individual studies, comparing early physical therapy vs delayed physical therapy. Patients receiving therapy within 30 days of index had a significant reduction in opioid use, spine injections, and spine surgery in early therapy jobs. Furthermore, a dose-response relationship was noted, with a significant decrease in health services utilization, ranging from $2,750 used in the first year after immediate PT, versus $5742 being used in the same time frame for patients receiving therapy after 6 months of initial pain symptoms. This review emphasizes the need for physiatrists to approach pain control using the biopsychosocial pathway, involving all modalities and allied health members to address the underlying issue. Therapeutic exercise, neuromuscular reeducation and self-training management are key components of pain control, requiring early evaluation and treatment by therapy.

The two articles above help highlight the importance of a holistic physiatric approach toward pain control. Despite the availability of long-acting opioids and advanced interventional procedures, our basic training revolves around addressing pain from a functional aspect. Optimizing a multimodal pain regimen with therapies is our best initial approach for utilizing health service costs and reducing medical complications.

Sudeep Mehta is a PGY4 and chief resident in the Department of Physical Medicine and Rehabilitation at East Carolina University.

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