Tackling the Opioid Crisis: The role of Physiatry
by Robert D. Pagán-Rosado, MD
Pain affects nearly 50 million people in the United States and is the number one cause of disability in the country.[1] Approximately 12% of patients suffering from pain in the US reported chronic pain, while the rest reported short-term pain from diseases, injuries, or medical procedures. In the past years, the cost for chronic pain treatment in the United States ranges from $560 to $600 billion.[2] The leading cause of accidental mortality in the nation is drug overdose by opioid addiction, exceeding deaths caused by firearms and motor vehicle accidents.[3,4] Due to misinformation, psychosocial factors, and excessive opioid use in acute pain management, an opioid crisis has risen. While personalized medical assistance is expected from physicians, there is vast social stigma that leads to unrealistic expectations regarding pain management.[5] Many patients may still expect a detox-like experience from opioid use, thus underestimating the effect that psychosocial determinants have in their quality of life. Nonetheless, studies have reported that in some patients, use of opioids for chronic pain exacerbated symptoms and resulted in detrimental functionality.[6,7] Only by redirecting health policy towards a comprehensive, opioid-minimizing approach, can we properly address this opioid crisis.[8]
Literature has clearly shown that Physical Medicine and Rehabilitation (PM&R) is a vital component for pain management.[8] One of the most important aspects regarding physiatric care lies on its multidisciplinary approach to treat musculoskeletal and neurologic conditions. Physiatrists aim to improve quality of life and function through the use of exercise, non-opioid medications, interventional procedures, modalities, and addressing psychosocial elements that predispose patients to chronic pain. Studies have reported that when physiatrists affiliate with emergency medicine physicians to treat back pain, 80% fewer patients return within thirty days for the same chief complaint.[9] In addition, research has also shown that fewer back surgeries are performed when PM&R is consulted before elective spine surgeries.[10]
It is important to stress the main issues that prevent adequate pain management by physiatrists and perpetuate the use of opioids. First, funds for research projects based on non-pharmacological management, functionality and quality of life for pain-suffering patients was historically lacking until recently.[11] Less than 2% of a $30 billion budget for biomedical investigations was spent on pain management related projects by the National Institutes of Health (NIH) before 2018. Second, the limited amount of therapy sessions approved by health insurances and their high out-of-pocket costs lead to an underuse of these physical modalities that are fundamental for chronic pain management and function.[8,12] Moreover, low cost opioid treatment in comparison to physiatrist-led pain rehabilitation programs, as well as less access for these programs, pose a challenge for physiatrists to provide a safe option for pain management.
There are some ways the field of physiatry can tackle the opioid crisis. The first step includes incorporating medication, medical equipment, nerve blocks, exercise, neuromodulation, and behavioral treatments into pain management and research. These non-opioid interventions curtail opioid-derived mortality as well as the socioeconomic burden in the country. Second, the focus of the results in pain research must be directed toward long-term patient follow-up, function and overall quality of life. Third, community outreach programs can be designed to educate patients about non-pharmacological pain management and the role of a physiatrist-led multidisciplinary programs to address pain and the opioid crisis. Additionally, physicians should focus their treatment on not only symptoms, but also patient priorities and goals in order to significantly impact patient satisfaction.[13] A satisfied patient who feels he or she can trust a physician’s plan may be more adherent with a multidisciplinary treatment.
Finally, there is medical education that must be addressed. Graduate and post-graduate medical education should emphasize the importance of pain rehabilitation, the challenges physicians face when treating pain, and the safe use of opioids.[8] Training healthcare providers in addressing external synergistic factors that contribute to pain can also help address the opioid crisis. As physiatrists, our job is not only to relieve pain but to provide better outcomes for our patients through improved quality of life and function. We want our patients to rely on safe measures to treat pain and continue with their life goals and hobbies. This is what physiatry is all about.
References:
1. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR Morbidity Mortality Weekly Reports (CDC). 2018;67(36):1001–1006.
2. de Leon-Casasola OA: Opioids for chronic pain: new evidence, new strategies, safe prescribing. Am J Med 2013;126: S3–11
3. Paulozzi LJ: Vital signs: overdoses of prescription opioid pain relievers- United States, 1999–2008. MMWR Morb Mortal Wkly Rep 2011; 60:1487–92.
4. Nuckols TK, Anderson L, Popescu I, et al: Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med 2014; 160:38–47
5. Young K, Zur J. Medicaid and the opioid epidemic: enrollment, spending, and the implications of proposed policy changes. Available at: https://www.kff. org/report-section/medicaid-and-theopioid-epidemic-enrollment-spendingand-the-implications-of-proposedpolicy-changes-issue-brief
6. Braden JB, Young A, Sullivan MD, et al: Predictors of change in pain and physical functioning among post-menopausal women with recurrent pain conditions in the women’s health initiative observational cohort. J Pain 2012; 13:64–72
7. Hina N, Fletcher D, Poindessous-Jazat F, et al: Hyperalgesia induced by low-dose opioid treatment before orthopaedic surgery: an observational case–control study. Eur Anaesthesiol 2015; 32:255–61
8. Pavlinich M, Perret D, Rivers WE, Hata J, Visco C, Gonzalez-Fernandez M, Knowlton T, Whyte J. Physiatry, Pain Management and the Opioid Crisis: A Focus on Function Association of Academic Physiatrists Position Statement Addressing the Opioid Crisis. Am J Phys Med Rehabil. 2018
9. Haig AJ, Uren B, Diaz K, et al: FastBack: The consequences of a reproducible complex consultation process on emergency department management of back pain. Orlando, Florida, Presented at the Academy Health 2012 Annual Research Meeting, June 24–26, 2012
10. Fox J, Haig AJ, Todey B, et al: The effect of required physiatrist consultation on surgery rates for back pain. Spine 2013; 38: E178–84
11. Help support a landmark pain research funding bill- U.S. Pain Foundation. Available at: https://uspainfoundation.org/news/help-support-landmark-pain-research-funding-bill. 2018.
12. How much does physical therapy cost? Available at: https://www.thumbtack.com/p/ physical-therapy-cost. 2017.
13. Tinetti, Mary, et al. “Challenges and strategies in patients’ health priorities-aligned decision-making for older adults with multiple chronic conditions.” PloS one 14.6. 2019
Robert Pagán-Rosado is a PGY1 at Hospital Episcopal San Lucas in Puerto Rico and future Resident in the Department of Physical Medicine and Rehabilitation at the Mayo Clinic. Follow him on Twitter @rdprMD.
