by Vicky Lu and Lauren Limbach

The opioid epidemic is a large burden on the American healthcare system. In 2015, opioid overdoses were responsible for over 140,000 emergency department visits and estimated to cost $152.8 million for the medical industry (1). By 2016, 11.5 million Americans were misusing prescription opioids, 2.1 million individuals had an opioid use disorder, and more than 42,000 individuals had died from an opioid overdose (2).  Additionally, while the U.S. comprises only 5% of the world’s population, Americans consume 80% of the world’s opioid pain medications (3).

Opioid analgesics are commonly used to alleviate both acute and chronic pain. While the use of opioids for short-term, acute pain management has been shown to significantly lower pain levels and is deemed medically necessary for pain treatment, researchers still caution medical practitioners against prescribing large supplies of opioids at a time (5, 6). Unlike acute pain, chronic pain is much more challenging to treat, and the efficacy of opioid treatment remains more controversial (4,5). Common examples of chronic pain are low back pain, neck pain, joint pain, orthopedics, severe headaches, and dental conditions (4). The main concern with using opioid treatments for chronic pain is that while opioids have significant analgesic efficacy, their long term costs and effects may be devastating. Independently, chronic pain and opioid addiction are difficult to treat, and their comorbidity only increases the difficulty of achieving effective treatment and decreases the individual’s quality of life (7). Chronic pain itself can induce structural and functional changes in the central nervous system, perpetuating the perception of pain; likewise, the long term use of opioids can lead to potential loss of efficacy  and opioid-induced hyperalgesia (6).

Back pain is the second most common complaint for which patients seek medical attention in the United States (8). Up to 11% of patients suffering from back pain experience symptoms for over three months (9). There are a myriad of treatment options available for addressing chronic back pain, ranging from lifestyle alterations to physical therapy. However the most common approach to treating chronic back pain is pharmaceutical intervention (10). A joint set of guidelines supported by both the American College of Physicians and the American Pain Society suggests that patients receiving a prescription to manage their chronic back pain should start with non-steroidal anti-inflammatory drugs (NSAIDs) (11). Despite these guidelines, one-third of patients who seek medical care for chronic back pain receive an opioid prescription within twelve months of their initial appointment (12). 

The current high rates of opioid prescription for lower back pain do not align with the literature examining the ability of opioids to treat chronic back pain. A particularly concerning research gap is the fact that there are essentially no studies that investigate the long-term efficacy and consequences of using opioids to treat chronic pain (13). Furthermore, amongst the short-term studies that look at opioid use for chronic back pain, there has been little to no indication that opioids are more effective than other classes of pharmaceuticals in relieving pain (14). In most of these studies, the minor to moderate benefits of using opioids to treat chronic pain are not weighed against the potential negative consequences of long-term opioid use (11).

In addition to the unclear efficacy of using opioids to treat chronic pain, there are many negative side effects that may accompany long-term opioid use. Through the late 1990s and early 2000s, opioid prescription rates rose concurrently with prescription drug abuse, highlighting the dangers of over-prescribing opioids for chronic pain (15, 13). Opioid use for treating chronic pain has also been shown to put individuals at risk for a variety of serious complications including overdose, abuse/dependence, bone fractures and myocardial infarction (13). It is estimated that approximately one quarter of patients taking opioids for chronic pain engage in medication-taking behavior that qualifies as abuse (8). Within just one to three months of daily opioid use, patients will experience opioid withdrawal (6). Furthermore, patients with a substance use disorder and co-occurring physical pain are more likely to misuse opioids, have more intense cravings, and are at a higher risk of illicit opioid use (7).

The dangers surrounding current protocols for pharmaceutical management of chronic back pain highlight the importance of optimizing physical therapy programs for chronic back pain. Currently 30% of patients who seek medical attention for chronic lower back pain receive an opioid prescription, while only 20% of patients attend physical therapy (12). When the effectiveness of physical therapy programs increases, more patients and doctors may choose to rely on physical therapy (PT) as opposed to potentially dangerous pharmaceutical treatments. This was a recommendation made in the CDC’s Guideline for Prescribing Opioids for Chronic Pain, which notes that PT may in fact be more effective at treating chronic pain compared to opioids (16). Esurgi has developed the Biostabilizer, a pressure biofeedback unit (PBU) with a one button setup and administration feature. Cost-effective and responsive physical therapy tools such as Esurgi’s Biostabilizer will increase the ability of physical therapy programs to effectively administer rehabilitation exercises that best address each individual’s experience of lower back pain. Would you find solutions such as the Esurgi Biostabilizer a helpful tool for optimizing the physical therapy process of treating chronic lower back pain? What features make PBUs useful in healthcare workflow?

Sources: 

1. Nicholas E. H. Introduction to the Opioid Epidemic: The Economic Burden on the Healthcare System and Impact on Quality of Life. AJMC. Accessed September 13, 2020. https://www.ajmc.com/view/intro-opioid-epidemic-economic-burden-on-healthcare-system-impact-quality-of-life

2. Division (DCD) DC. Opioid Crisis Statistics. HHS.gov. Published May 8, 2018. Accessed September 13, 2020. https://www.hhs.gov/opioids/about-the-epidemic/opioid-crisis-statistics/index.html

3. Manchikanti L, Singh A. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician. 2008;11(2 Suppl):S63-88.

4. Janakiram C, Fontelo P, Huser V, et al. Opioid Prescriptions for Acute and Chronic Pain Management Among Medicaid Beneficiaries. Am J Prev Med. 2019;57(3):365-373. doi:10.1016/j.amepre.2019.04.022

5. Salsitz EA. Chronic Pain, Chronic Opioid Addiction: a Complex Nexus. J Med Toxicol. 2016;12(1):54-57. doi:10.1007/s13181-015-0521-9

6. Deyo RA, Von Korff M, Duhrkoop D. Opioids for low back pain. The BMJ. 2015;350. doi:10.1136/bmj.g6380

7. Smallwood RF, Price LR, Campbell JL, et al. Network Alterations in Comorbid Chronic Pain and Opioid Addiction: An Exploratory Approach. Front Hum Neurosci. 2019;13. doi:10.3389/fnhum.2019.00174

8. Martell, B. A., O’connor, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., & Fiellin, D. A. (2007). Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction. Annals of Internal Medicine, 146(2), 116. doi:10.7326/0003-4819-146-2-200701160-00006

9. Chaparro, L. E., Furlan, A. D., Deshpande, A., Mailis-Gagnon, A., Atlas, S., & Turk, D. C. (2014). Opioids Compared With Placebo or Other Treatments for Chronic Low Back Pain. Spine, 39(7), 556-563. doi:10.1097/brs.0000000000000249

10. Kuijpers, T., Middelkoop, M. V., Rubinstein, S. M., Ostelo, R., Verhagen, A., Koes, B. W., & Tulder, M. W. (2011). A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. European Spine Journal, 20(1), 40-50. doi:10.1007/s00586-010-1541-4

11. Chou, R., Deyo, R., Friedly, J., Skelly, A., Weimer, M., Fu, R., . . . Grusing, S. (2017). Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Annals of Internal Medicine, 166(7), 480. doi:10.7326/m16-2458

12. Azad, T. D., Zhang, Y., Stienen, M. N., Vail, D., Bentley, J. P., Ho, A. L., . . . Ratliff, J. K. (2019). Patterns of Opioid and Benzodiazepine Use in Opioid-Naïve Patients with Newly Diagnosed Low Back and Lower Extremity Pain. Journal of General Internal Medicine, 35(1), 291-297. doi:10.1007/s11606-019-05549-8

13. Chou, R., Turner, J. A., Devine, E. B., Hansen, R. N., Sullivan, S. D., Blazina, I., . . . Deyo, R. A. (2015). The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Annals of Internal Medicine, 162(4), 276. doi:10.7326/m14-2559

14. Enthoven, W. T., Roelofs, P. D., & Koes, B. W. (2017). NSAIDs for Chronic Low Back Pain. Jama, 317(22), 2327. doi:10.1001/jama.2017.4571

15. Olsen, Y., Daumit, G. L., & Ford, D. E. (2006). Opioid Prescriptions by U.S. Primary Care Physicians From 1992 to 2001. The Journal of Pain, 7(4), 225-235. doi:10.1016/j.jpain.2005.11.00616. Chaparro, L. E., Furlan, A. D., Deshpande, A., Mailis-Gagnon, A., Atlas, S., & Turk, D. C. (2014). Opioids Compared With Placebo or Other Treatments for Chronic Low Back Pain. Spine,39(7), 556-563. doi:10.1097/brs.0000000000000249

16. Chaparro, L. E., Furlan, A. D., Deshpande, A., Mailis-Gagnon, A., Atlas, S., & Turk, D. C. (2014). Opioids Compared With Placebo or Other Treatments for Chronic Low Back Pain. Spine, 39(7), 556-563. doi:10.1097/brs.0000000000000249

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