The US Centers for Disease Control and Prevention's (CDC's) draft clinical guidelines on the use of opioids for chronic pain make it clear: drug-free approaches such as physical therapy are the "preferred" treatment path for chronic pain.
The American Physical Therapy Association (APTA) is in full agreement.
This week, APTA submitted comments to a new CDC document aimed at primary providers who may prescribe opioids to treat chronic pain. The guidelines attempt to rein in growing rates of opioid use disorder and opioid overdose, and to help reduce the prevalence of opioid prescriptions, which topped 259 million in 2012—"enough for every adult in the United States to have a bottle of pills," according to the CDC.
The guidelines were developed after expert review of evidence around not only the effectiveness of opioids (and their dangers), but also the ways in which non-drug approaches can be used in treatment. After evaluating the evidence, the CDC drafted recommendations around determining when to initiate or continue opioids for chronic pain, as well as guidelines for drug selection and dosage, and risk assessment.
Recommendation #1: “Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain."
"Based on contextual evidence, many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, complementary and alternative therapies (e.g., manipulation, massage, and acupuncture), psychological therapies such as CBT, and certain interventional procedures can ameliorate chronic pain," the draft states. "In particular, there is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip … or knee … osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2–6 months."
In its comments to the draft, APTA applauds the recommendations, stating that approaches such as physical therapy "have been underutilised, and, therefore, can serve as a primary strategy to reducing prescription pain medication abuse and improving the lives of individuals with chronic pain."
APTA's comments also note that referral to exercised-based interventions "is essential prior to the initiation of opioid-based therapy," and that exercise interventions "have the potential to improve health outcomes, reduce costs, and decrease the risks associated with opioid prescriptions."
The association goes on to recommend that the CDC provide clear guidance on the patient populations that would benefit from non-drug approaches, and that more extensive patient education resources should be developed on the benefits of exercise-based interventions over opioid prescriptions. This education needs to be aimed at both the public and primary care providers, ATPA writes.
APTA also added its support to CDC recommendations around the use of multidisciplinary approaches to management of chronic pain, such as a combination of physical therapy and cognitive-based interventions. The problem, the association points out, is that although supported by evidence, the approaches "have been challenged by reimbursement policies." APTA recommends that the use of multimodal approaches to treat chronic pain be part of a broader effort to change payment policies in ways that make them more amenable to non-drug approaches to chronic pain.
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