Threshold Physical Therapy and Performance Stuck Struggle

Opioid-Induced Hyperalgesia and Opioid-Slowed Healing

by Pain And Its Management
Threshold Physical Therapy and Performance Stuck Struggle

As we talked about here, your opioids are not doing what you think they are…

Dr. Alan Jette, PT, PhD, FAPTA and editor in chief of Physical Therapy Journal eloquently noted, health policy action is urgently needed to alleviate the US health care system’s long-standing preoccupation with pharmacological approaches to pain management. This is so deeply indoctrinated that a 2016 survey noted 67% of doctors are, in part, basing their prescribing decisions on patient expectations, this is resulting in patients learning to associate quality of care with the liberal use of pain killing medications.

A 2008 article written by Mitra, defines opioid-induced hyperalgesia as a phenomenon whereby opioid administration results in a lowering of pain threshold, clinically manifest as apparent opioid tolerance, worsening pain despite accelerating opioid doses, and abnormal pain symptoms such as allodynia.

Wait… So we’re taking a medication to help with pain management, but it’s actually making our symptoms worse? Yep, you’ve got it!

Often times you’ll hear individuals who has been on opioid-based pain medications for longer periods of time say that their meds don’t really help anymore, regardless of how much they take… Or,  that their symptoms seem to have gotten worse over the past months or years and they worry that something else is wrong or their condition is worsening…

It is important to keep in mind that pain is a warning signal, an alarm of sorts, and sometimes alarms let us know that something is wrong and sometimes they go off on accident. Consider that taking these opioid-based pain medications actually makes the alarm system more sensitive with more accidental warning signals and alarms. Instead of the system going off when a burglar is breaking in, it is going off when a bug tries to get in through the window…

The other thing that needs to be considered in a different light is notion these medications are the best way to treat pain and somehow necessary and help with the healing process improving quality of life. Interestingly, two articles, one in JAMA (2018) and the other in Health Services Research (2018) lending evidence to the fact that these notions are, in fact, false. 

We see that for chronic low back, hip, and knee pain (at least) opioid medications were no better than non-opioid medications with regards to pain-related function over 12 months.

Additionally, individuals utilizing “opioid therapy” for chronic noncancer pain noted a lower health-related quality of life when compared to their counterparts.

Lastly, the American Academy of Orthopedic Surgeons, in a 2016 release, noted that those who decrease their pre-surgical opioid intake prior to surgery are more likely to have improved outcomes, decreased complications, and reduced post-surgical opioid use. Along the same lines, a 2018 article found that in a population suffering physical trauma, when compared to opioid-naïve (non-users) patients, opioid-dependent patients had longer length-of-stay in the hospital, more days on a ventilator, more non-home discharges, and higher readmission rates.

Take Home: not only are these medications addictive and dangerous, they are no better at controlling painful symptoms than over the counter medications after a fairly short period of time, they slow down or complicate the healing process, and they actually make your painful symptoms worse over time!

Additional Reading:

Why Exactly Are Opioids So Bad?

Physical Therapy First For Pain Management And Accelerated Healing

Threshold Physical Therapy and Performance Thoughtful Skeleton

Physical Therapy First For Pain Management And Accelerated Healing

by Pain And Its Management
Threshold Physical Therapy and Performance Thoughtful Skeleton

As we touched on here, conservative treatment (like Physical Therapy/Physiotherapy) is a first line defense for pain management and helping to deflect the opioid-overdose death curve.

It would seem that most, if not almost all, people would agree that exercises is good for the body and the mind. Some with pain (both chronic and acute) shy away from physical activity and exercise because they don’t want to make something worse and it … well, it just hurts!

Exercise-induced analgesia is the phenomenon whereby physical activity and exercise result in a decreased perception of one’s painful symptoms. It is thought that appropriate exercise alters the immune system and pain inhibitory pathways at the level of the central nervous system (brain and spinal cord).

What does this mean? Well, with a tailored exercise and activity plan we are able to create changes in our nervous system. Since this is the system that is carrying nociceptive (potentially harmful stimuli) signals, perceiving signals as painful, and the same system that is affected by those opioid-based medications we are able to have a decrease in painful symptoms.  

From a pain science perspective, it’s important to consider that pain and tissue damage are not always connected. Medicine is moving from a biomedical model (tissue damage equals pain where fixing the “damage” fixes the pain response) to a biopsychosocial model (pain can arise and be propagated by biologic, psychologic, sociologic factors, each of which can increase or decrease a pain response). Considering this holistic pain-contributing mindset allows physical therapists to help more completely treat the pain response and improvem someone’s function.

While we’ve seen that opioids can slow down the healing process and decrease quality of life, we know that a tailored exercise program can improve quality of life, decrease the risks of many noncommunicable diseases, and help to modulate painful symptoms and disability. 

Another interesting, and I think pertinent point, is that not being on opioids will save you money in the long, and short, run…

According to information compiled by Optum Data, in addition to the direct medical costs, opioids make up one-quarter of all workers’ compensation prescription drug costs and, when considering cost of care paid by insurances companies, amounts paid by insurance companies for ordinary (non-opioid-abusing) patients ($3,435) compared to the average $19,333 for patients with an opioid abuse or dependence diagnosis.

Can physical therapy actually help to speed the healing process? While it probably isn’t going to make a bone heal faster, research shows that exercise programmes starting at an appropriate time postsurgery lead to a faster decrease in pain and disability when compared to no treatment.

This is only one example of many! If you’re dealing with pain, finding yourself unable to leave opioids behind, considering surgery, coming out of a surgery, or are just curious … reach out to your local physical therapist and get yourself feeling better and moving better!

Additional Reading:

Why exactly are opioids so bad?

Opioid-Induced Hyperalgesia and Opioid-Slowed Healing

Threshold Physical Therapy and Performance Blog: Chronic Pain, Opioid Addiction, and what we now know...

America’s Pain Problem and the Opioid Mistake

by Pain And Its Management

America’s Pain Problem And The Opioid Mistake

Threshold Physical Therapy and Performance Blog: Chronic Pain, Opioid Addiction, and what we now know...

 

Pain is unique in that it is a universal, yet notable individualized experience. 

According to a 2011 report approximately 100 million U.S. adults suffer from chronic pain costing $560-635 billion annually in direct medical treatment costs and lost productivity. At the same time, the CDC reports that between 1999 and 2016 more than 630,000 people died from drug overdose – over 350,000 of these involved prescription and illicit opioid overdoses. Rather than a problem with a solution, evidence is pointing to a problem with another, overlying and more complex, problem. 

The bad news, with the current trends it’s looking to only get worse… With a nearly perfect exponential curve of overdose deaths over the last 37 years, the U.S. is projected to suffer an additional 300,000 opioid-related overdose deaths between 2015 and 2020. 

So, Why Exactly Are Opioids So Bad?

Serious question here: Would you do heroin? 

It may seem like an exaggeration and for most the answer is a definitive “NO”, but when you look at the chemical similarities between heroin and “safe” opioid medications like Hydrocodone and Oxycodone, you’ll see that not only is their chemical structure similar, their nervous system effects and addictive qualities are as well… Interestingly, it has been found that opioid medications are addictive in as few as 3-5 days of use. 

So, besides providing the perception of decreased pain and symptoms, what else do opioid-based medications do? Consider:
     • Confusion
     • Nausea
     • Constipation
     • Euphoria
     • Hypoxia (there’s the overdose death kicker…)

Hypoxia – a condition that results when too little oxygen reaches the brain. Things get a bit more complicated here, but ultimately the brain needs oxygen. When it is deprived for too long, for example when falling asleep or passing out after overdosing on opioids or mixing opioids with say, alcohol, our breathing rate can decrease to nonviable levels. Decreased breathing rate can result in coma, permanent brain damage, and death. The complexity comes in that, in a lower risk state-of-being and when the activity is self-limiting, we can use hypoxic training to increase aerobic sport performance. To be clear, I’m not attempting to connect opioids with sport performance. More on that in the future…

So, besides a significant number of people dying, what else makes opioids so bad? Check it out here…

Stay away from things that are unnecessarily dangerous, slow the healing process, and make your symptoms worse in the long-run...

Drugs are bad mkay…

Ok, not all drugs, but as a nation we’re seeing that opioid-based pain medications play a minimal role in the middle and end-game of pain management and injury recovery. Along this line, I’d like to introduce the concept of opioid-induced hyperalgesia…

As noted in the literature, opioid-induced hyperalgesia refers to the phenomenon whereby opioid administration results in a lowering of pain threshold, clinically manifest as apparent opioid tolerance, worsening pain despite accelerating opioid doses, and abnormal pain symptoms such as allodynia.

Great, but what does it mean!?!? Well, that thing that you’re taking to decrease your pain, it’s making your pain worse over time. Additionally, a 2018 study from the Journal of the American Medical Association (JAMA) found no difference in pain-related function over 12 months between the use of opioids (immediate-release morphine, oxycodone, or hydrocodone/acetaminophen) as opposed to the use of acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. 

Another important consideration, they slow down healing. Most people I work with take or seek pain medications because they have had an injury or surgery. According to the American Academy of Orthopedic Surgeons (AAOS), decreased opioid use prior to joint replacement surgery correlated with improved patient satisfaction and outcomes, fewer complications, and a reduced need for post-surgical opioids.

So, let’s get this straight, we’re taking something to help with our pain and help get us better, but (after a fairly short period) it results in slowing our functional progression and increasing our symptoms. 

Want to dive deeper? Click here…

Physical Therapy First For Pain Management And Accelerated Healing

The National Academies of Sciences, Engineering and Medicine (NASEM) conducted a consensus study to characterize the opioid epidemic and recommend actions. The report notes that physical therapy is often included in the treatment plan offered to patients who have musculoskeletal pain conditions such as fibromyalgia and arthritis, as well as back and neck pain. 

Additionally, when considering low back pain, seeing a conservative practitioner whose clinical decision-making is aligned with current clinical evidence first, the severity-adjusted total episode cost, including all treatment provided by any type of provider in any setting, is approximately 30 percent lower than the overall average total episode cost for treatment of back pain.

So, what can physical therapy offer? Since pain is a noxious sensory AND emotional experience. It is important to appreciate the influence of sociological and psychological factors on pain, as well as the concept that pain and tissue damage are not always correlated as closely as we think.  

Utilizing a multifaceted and biopsychosocial model physical therapists can facilitate the body’s own, endogenous pain relief systems, as well as promote improved musculoskeletal function and biomechanics, tissue desensitization, provide neuroscience education, and assist in building activity tolerance. 

Check out this post for more…

Opioids and Metabolic Diseases (...like type II diabetes)

Some 2010 research by Mysels and Sullivan provided some interesting insights into how sugar intake and consumption may affect the endogenous opiate system. Chronic opioid exposure is associated with increased sugar intake, with the theory that exposure to certain kinds of of opioids  may result in a heightened taste preference for high-sugar foods.

Interestingly, it has been found that >30% of caloric intake was sugar in a particular opioid population and glycemic dysregulation associated with chronic opiate administration manifest clinically. 

As the evidence grows linking the opioid system to food intake and risk of obesity, clinicians should reinforce proper exercise and dietary habits with opioid-dependent individuals. 

 

Threshold Physical Therapy and Performance Chained To The Opioids

Why exactly are opioids so bad?

by Pain And Its Management
Threshold Physical Therapy and Performance Chained To The Opioids

As we began to discuss here, opioids are dangerous, addictive, and have overtaken automobile accidents as the leading cause of accidental death in the U.S.

There is no denying that pain in the United States is a significant and serious problem. With over 100 million Americans suffering from chronic pain that is costing $560-635 billion per year in direct medical costs and lost productivity (2011 findings), this is something that needs to be managed. In the late 1980’s and early 1990’s prescription opioids were being provided more readily to help with the growing pain problem. Not surprisingly, the CDC found the first wave of opioid overdose deaths corresponding with this attempted to manage America’s pain in the early 1990s. 

Jumping ahead, this same research helps to solidify the point that we are on a train heading in a bad direction… In 2016, the number of opioid overdose deaths was 5x higher than 1999. Additionally, it has been found that as opioids become less effective (a tolerance is built) and doses become higher, patients who receive high-dose opioid prescriptions face a risk of overdose and death that is nine times higher than low-dose patients. 

So, what’s the mechanism? Why are they so dangerous?? As reported by the World Health Organization, opioids are psychoactive substances that affect the brain stem where breathing is regulated. With increased opioid intake, or mixing opioids with alcohol and/or other sedative medications, respiration (breathing) is depressed (slowed) excessively. While slowed breathing is not typically an issue if someone is awake and able to actively think about their breath, unconsciousness is another of the “opioid overdose triad” signs and symptoms. So, medically/pharmaceutically depressed respiration coupled with unconsciousness is a recipe for a fatal drug overdose.

Other unfortunate facts:
– 21% of individuals who take opioids for the first time have issues with opioids in the future.
– Opioids slow down the healing process and increase post-surgical complications
– Over 100 people in America die every day from opioid overdoses
– Many opioid abusers have access to prescription opioids through family members and friends
– Every 15 minutes a baby that is addicted to opioids is born
– Opioids are addictive in the first 3-5 days, leading to dependence
– Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months
– America is projected to have over 300,000 opioid-related deaths between 2015 and 2020

Additional Readings:

Physical Therapy First For Pain Management And Accelerated Healing

Opioid-Induced Hyperalgesia and Opioid-Slowed Healing

Service (…and what it means)

by Service

What Healthcare can learn from the Service Industry

To give real service you must add something which cannot be bought or measured with money, and that is sincerity and integrity. ~Douglas Adams

 

Threshold Physical Therapy and Performance Service Table Service

Consider the last time you went out and had an exceptional experience. I mean truly exceptional. Everything about the experience was perfect. From start to finish the ambiance was exactly what you were looking for, the table was perfect, the food hit the spot, and the services provided everything you needed and nothing you didn’t. I would wager to bet that you were greeted warmly at the host stand, you had the comfortable table you wanted, you were quickly greeted by the individual serving you, they were friendly and helpful, the wait for food and drinks was appropriate and comfortable, everything you ate and drank was delicious, someone was there if you needed anything, your server was ready with your check when you wanted to go and you weren’t “held hostage”. This all results in a seamless and deeply enjoyable experience.

 

Threshold Physical Therapy and Performance Coffee ServiceLet’s contrast this with how most medical visits seem to go… You show up and wait to be greeted by someone who acts like you’re making their life more difficult. You’re put in an uncomfortable space and you wait … and wait … and maybe wait some more. Then, the person you’re there to see comes in and rushes through their questions. Maybe your questions get answered, maybe they don’t… After the whirlwind experience, feeling unfulfilled, you head back out to wait for someone to get off the phone so that you can schedule, or pay, or get information to see another or a different medical provider.

 

If we’re being honest, you can have this sort of poor experience at a restaurant as well. It’s also fair to comment that not all medical visits play out this way. The point could be made that even if you remove the products, whether is be food or medication, drinks or imaging, there are a lot of other components of the experience that can bring it closer to that exceptional level. Carl Buehner, in 1971, is ascribed to the statement, “They may forget what you said – but they will never forget how you made them feel”. Healthcare needs to realize that while we’re making people feel better, we’re not making people feel better.

Personally, I blame third party payers and insurance companies… Deductibles and co-pays go up while clinician reimbursement goes down, and you know that money is going somewhere (9% growth to $201 Billion in 2017 for one company). In order to pay back somewhere around a quarter-million in student loan debt (per physician), or keep a clinic in business, more people need to be seen per hour per day. This is going to push both clinicians and support staff to their limits. Are costs out of control? Yes, without a doubt. But, that is another post for another time… This is all a little besides the point since it is more of an excuse and doesn’t really provide any solutions.

 

Threshold Physical Therapy and Performance Coffee Service Table ServiceSo, we’re starting to see research being done on non-cognitive skills, therapeutic alliance, emotional intelligence, and the like… We’re starting to realize that research done by John Bowlby (1907 – 1990) holds weight not only with children, but with adults in relationships. What would we call patient-centered care between the patient and clinician? Oh, a relationship… Relationships take time, patience, humor, and two-way communication. Quality service requires attention, having everything you need and nothing you don’t, a sense of comfort, shared goals, and no one holding you hostage.

 

So, as clinicians we need to keep in mind that we’re building relationships and we’re providing a service. In the current atmosphere we don’t have much control over the time, but let’s consider the other factors that make strong relationships. What does 10-star service look like? Even with our education, and degrees, and doctorates, and experience, and biases, what can we pull from hosts, hostesses, servers, bartenders, and wait staff who are buried and in the weeds but still create exceptional experiences. How can we work to connect with the client or patient sitting in front of us in a way that helps them to feel heard and cared for when they are seeking exactly that – care? What can we do better when it comes to the services we provide? -M