How Physical Therapy Can Help Reduce Opioid Use
Locally, the Oregon Health Authority states that “unintentional opioid-related overdose is one of Oregon’s leading causes of injury mortality”. Nationally, the bipartisan opioid commission recommended that an emergency be declared in an effort to save lives, as the number of American deaths due to opioids has increased over 400% since 1999 (CDC, 2015). Costs to society related to medical care, crime, lost productivity and social welfare of opioid dependence are estimated to be in the billions (Drug Alcohol Dep 2001).
How did this happen?
There’s plenty of blame to go around: pharmaceutical companies for controversial sales tactics, physicians for prescribing opioids for extended periods and patients for not questioning their doctors on more effective ways to treat chronic pain. Regardless, the medical profession is feeling the urgency to find alternative cost-effective treatments for those with chronic pain as well as those who are opioid-dependent.
Standard medical treatment for addiction, such as methadone maintenance therapy (MMT) and buprenorphine, may relieve opioid cravings, reduce withdrawal symptoms and block opioid euphoric effects (American J Addictions 2014). However, there are serious problems in relying on these treatments alone, including Hepatitis B and C viruses, HIV, major depression, other substance use disorders, high drop-out rates and poor quality of life (Drug Alcohol Dep 2010, Biological Psychiatry 2004). Further, research shows that simply replacing one drug with another often leads to extended treatment along with reduced retention and success (American J Addictions 2009). In other words, drugs alone are unlikely to be successful in treating chronic pain and/or opioid addiction.
You saw this coming.
One cost-effective adjunct treatment for chronic pain andopioid addiction is exercise therapy (ET). Carrying zero side effects, properly prescribed ET can serve as a healthy behavioral substitute for the opioid addicted by boosting socialization, regulating emotion and managing stress while reducing anxiety, risk of major depression relapse, urges to drink alcohol, nicotine withdrawal and cravings for cannabis and cigarettes (Addictive Behaviors 2008; J Sport Exercise Psychology 2006, 2008; Behavior Modification 2007).
ET’s ability to regulate emotion and reduce anxiety is particularly important, as both are risk factors for developing substance use disorders. Properly prescribed ET provides safe “repeated exposure” to anxiety-like sensations such as rapid heart rate, breathing and sweating, which can eventually reduce reactivity to these sensations and lead to reduced substance use (Clinical Psychology Rev 2001, 2006). Note that opioids work by temporarily giving people feelings of euphoria, followed by a fall below normal and return to a “set point”. Sustained, long-term opioid use lowers this set point, leading to higher doses to achieve an effect and eventual dependence (Mental Health Physical Activity 2009). This is why people have withdrawal symptoms (e.g., depression, anxiety) when trying to get off opioids that are alleviated by using more (and more) opioids.
Opioids are often prescribed in treating chronic pain (especially low back pain), contradicting research as well as the World Health Organization (2016), which suggest that in the majority of chronic pain cases, non-drug treatments (e.g., ET) should be prescribed over opioids (Archives Physical Med Rehab 2010, 2013; JAMA 2005; Pain 2009).
ET works by serving as an effective “euphoria substitute” by releasing endogenous opioids that have chemical properties similar to heroin and morphine in the brain, spinal cord and peripheral nervous system, making ET a compatible drug substitute (Methods 2008; Cerebral Cortex 2008; Sports Medicine 1997). Another reason ET should be prescribed: many people who are opioid-dependent have other lifestyle-related health problems (e.g., diabetes, heart disease, alcoholism, obesity) that could be concurrently treated using ET (Preventive Medicine 2010; American J Addictions 2009). To be effective long-term, the ET program should include strength training, endurance exercise and stretching at an appropriate difficulty so patients achieve benefit without risk of injury and/or dropout (New Eng J Medicine 2006; ACSM 2007, 2010). Sleep quality and dietary modification should also be included to foster recovery, fat loss and quality of life (Arch Physical Medicine Rehab 2007).
How do medical professionals get patients to engage in an ET program? This can be difficult, as most medical schools do not train medical students/residents on ET prescription (British J Sports Medicine 2003; Lancet 2012) and motivating a patient to perform ET takes extra time most physicians aren’t willing to invest. Therefore, referral to a licensed physical therapist specializing in ET may be the best option, as ET is a covered service when prescribed by a licensed physical therapist.
Ultimately, the patient must actively coordinate with his/her physician to determine the best options available in avoiding opioids as well as getting off them if addicted. In most cases, ET must be included for long-term success.
Colin Hoobler is a Doctor of Physical Therapy and teaches continuing medical education to physicians on the use of ET to treat chronic disease.