by Rick Wickstrom, PT, DPT, CPE, CDMS
Assess Physical Function and Risks BEFORE Starting Opioid Therapy!
Opioids are commonly prescribed to alleviate pain. According to the National Survey on Drug Use and Health, 38% of all non-institutionalized adults in the US used prescription opioids in 2015 (1). Nearly 20% of all patients who presented to physician offices with non-cancer pain symptoms received an opioid prescription (2). One in five users who received an initial 10-day supply of opiates became chronic users (3). To reduce addiction and harm resulting from opioids, the Centers for Disease Control (CDC) issued a Guideline for Prescribing Opioids for Chronic Pain.
The evidence reviewed by the CDC found no studies that demonstrated a long-term benefit to pain and function for opioids compared to no opioids for outcomes measured at least one year later. This is because objective measures of physical function are not routinely collected by physicians to promote wellness and optimum pain management. There is extensive evidence of harm from taking opioids – including constipation, addiction, overdose, and death. Nonpharmacologic treatments and nonopioid pharmacologic treatments demonstrated more benefits compared to long-term opioid therapy, with less harm. The 12 key recommendations by CDC in this 2016 report were prioritized based on this evidence and the absence of credible, long-term studies of the benefits of opiates compared to safer, alternative therapies.
Objective Tests of Physical Function
Physicians often rely primarily on self-reported outcomes by patients to assess progress with pharmacologic and other pain therapies. For example, patients may be asked to rate the severity of pain using a numerical scale from 0 to 10 during the initial office or emergency visits. Some ambulatory care settings ask the patient to report the perceived impact of their health condition on physical function by completing a self-administered questionnaire such as the Oswestry Low Back Pain Disability Questionnaire. Simple, objective measures of physical function are readily available, but rarely used to guide treatment decisions or assess functional progress in response to pain therapies.
Best Practices for Managing Painful Conditions
- Communicate known risks and likely functional benefits of therapy options to the patient.
- Start with safe, non-drug therapies such as physical therapy or nonopioid medications.
- Measure baseline physical function and risks for opioid-related harms BEFORE starting opioids.
- Periodically assess changes from baseline pain, physical function measures, and side effects to determine if improvements from therapy outweigh risks for harm.
- Promote use of safe, nonopioid therapies to discontinue opioids or taper to lower dosages.
- Encourage resilience by emphasizing realistic, functional goals and suitable physical activity.
- Facilitate evidence-based treatment (medication-assisted combined with behavioral therapies) for patients that develop an opioid use disorder (addiction).
How Can We Bridge the Gap between Pain Management and Wellness Programs?
Health professionals need to routinely collect objective metrics about a patient’s prior level of physical function during wellness screens and before initiating opioid therapy for painful conditions. This provides an objective baseline to assess functional progress in response to wellness and healthcare interventions. Every patient that undergoes treatment for a painful condition should have convenient access to education and coaching to enable return to suitable functional activities that are necessary for a productive lifestyle. The functional progress report for patients treated for chronic pain should minimally include objective metrics of physical functioning such as active movement and agility. WorkAbility Systems offers a one day course on PhysicalFIT Screening to train fitness and health professionals on simple measures of physical function for wellness and pain management programs.
- Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Prescription OpioidUse, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Ann Intern Med. 2017 Sep 5;167(5):293-301.https://www.ncbi.nlm.nih.gov/pubmed/28761945
- Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND, Stafford RS, Kruszewski SP, Alexander GC. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Med Care. 2013 Oct;51(10):870-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3845222/
- Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:265–269. DOI: http://dx.doi.org/10.15585/mmwr.mm6610a1
- Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1