The opioid abuse epidemic affecting Kentucky and the United States has resulted in coordinated efforts between government officials and the medical community to impose restrictions on prescribing opium-derived pain medications, which grew in the late 1990s and helped to cause the current crisis. According to a recent report from the Centers for Disease Control, the sale of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014.
Along with a focus on stronger regulation of opioids, doctors and patient advocates have called for a broad-scale reassessment of how to manage chronic pain, one that incorporates medication but includes alternative treatments such as physical therapy, cognitive behavioral therapy, and pain education.
As part of KET’s ongoing Inside Opioid Addiction initiative, funded in part by the Foundation for a Healthy Kentucky, this episode of Health Three60 examines the scope of how pain is treated within the U.S. health care system. Host Renee Shaw and three guests from different disciplines – medicine, psychology, and physical therapy – discuss best practices for managing chronic pain, gaining a better understanding of the struggles patients have when living with pain, and learning more about treatments for chronic pain that don’t rely on medication.
Reversing the Rising Tide of Prescriptions
Dr. James Patrick Murphy, MD, MMM, is the founder, medical director, and CEO of Murphy Pain Center in New Albany, Ind., across the Ohio River from Louisville. He says the rise in prescriptions of pain medication beginning in the late 1990s was due to a “perfect storm” of several factors.
First, Murphy says, the medical community treated pain as a vital sign that could be controlled by medicine. Second, new opioids such as Oxycontin were covered by insurance companies, and these drugs were heavily marketed. Third, Murphy says that doctors and medical staffs did not have the education and experience at that time to be fully aware of the long-term effects of the new opioids.
Murphy details how opioids work to relieve pain in patients by attaching to opioid receptors in the brain. They are very good at deadening the effects of pain on the central nervous system, he acknowledges, but they also slow breathing, cause extreme drowsiness, and can lead to addiction. Murphy is careful to point out the distinction between addiction and dependence, however.
“Addiction is a disease of the brain, where there is craving, loss of control, and a heightened response and need for whatever substance a patient is addicted to – in some cases opioids,” he says. “Whereas physical dependence happens to everybody. … What that means is you’ve been taking the drug for a while, and it leaves your system, and there’s a withdrawal. Opioids can make you feel like you’re an addict because you’re shaking and you’re nervous, but that’s simply the drug leaving your system, that’s not addiction. That’s a huge difference.”
As physicians continue to gain understanding of addiction as a brain disease, they are devising more effective approaches to both improve the guidelines for prescribing opioid painkillers and to develop new methods for educating patients about pain.
Dr. Bill Elder, PhD, is a psychologist and director of behavioral health at the University of Kentucky Department of Family and Community Medicine. He is involved with an organization called the Central Appalachian Inter-Professional Pain Education Collaborative (CAIPEC), a joint effort between UK, the University of Pikeville, and West Virginia University. CAIPEC has modified prescription protocols in the Appalachian region by using technology, face-to-face patient consultation, and other interventions to change the approach for prescribing pain medications.
Elder says that understanding how patients each experience chronic pain in a highly individual manner has informed much of their work. By consulting with each patient and learning his or her story, doctors and clinicians can better determine the most effective treatment plan and adjust any prescriptions that are required.
“For example, a history of emotional, physical, or sexual trauma during childhood makes somebody much more susceptible to developing a chronic pain problem or addiction,” he says. “That doesn’t mean that they shouldn’t receive these medications to manage the pain, but you certainly have to be much more careful in helping that person with those medications, and they often need some other types of care.”
Murphy discusses screening measures a doctor should perform when initially meeting with patients to determine if an opioid prescription is the best approach for managing their pain. These include the usual lab tests and also consulting a patient’s KASPER report, which stands for Kentucky All Schedule Prescription Electronic Reporting.
The KASPER report was established as a key part of Kentucky’s House Bill 1 in 2012, and the legislation requires physicians to access each patient’s KASPER report to find out if they have solicited other doctors and/or pharmacists prior to their visit.
Murphy has some reservations with the legislation, feeling that it over-regulates a doctor’s ability to effectively treat patients, but Elder also points out that the bill allows doctors to share KASPER information with patients. This can help both parties arrive at the best path to treatment.
Living With Chronic Pain: A Personal Story
As part of the program, KET revisits Connie Johnson, who lives in Louisville and has had rheumatoid arthritis for about 30 years, beginning when she was as teenager.
Johnson originally appeared on KET several years ago, when she shared how devastating the disease has been to her body through the years. Multiple surgeries and a shoulder replacement led to depression, but Johnson summoned the willpower and created a therapeutic routine to manage her pain. The routine included regular swimming and water aerobics, support group meetings with other chronic pain sufferers, meditation, and very rewarding volunteer work at an animal rescue organization.
Johnson, interviewed recently in Louisville, says that she still maintains that routine and benefits greatly from it, but also acknowledges that she has used prescription opioids for more than 15 years to alleviate the chronic pain that affects her entire body. Getting her prescription refilled has become more difficult as the opioid addiction crisis grew in recent years, Johnson says, leaving her with feelings of despair and even shame even though she is only trying to relieve the symptoms of a debilitating disease.
Calling prescription opioids part of “my survival kit,” Johnson says that despite society’s current focus on the ways opioids can be abused, “I want people to understand that there are as many stories that are positive stories, and that are about people being able to live a life worth living, because of opioids, because of pain medicine.”
Elder says that Connie Johnson’s self-directed program involving physical therapy, support groups, and volunteering is ideal for patients who want to eventually end their use of prescription opioids. He says that is the ideal goal, because long-term opioid use has damaging effects – both physiological and psychological.
As a pain specialist, Murphy disagrees somewhat about long-term opioid use, saying that if a doctor is very careful and diligent, opioids can be useful. “If people take these medications properly, if they are properly screened and are appropriate candidates, and if you follow up closely and have a relationship with them, you can prescribe these medications safely.”
Effective Alternative Treatments for Managing Pain
Dr. Chad Garvey, PT, DPT, is the clinic director of KORT Physical Therapy in downtown Louisville. Garvey’s comprehensive treatment platform includes methods such as spinal manipulation, strength and flexibility exercises, and patient education about pain awareness and pain management.
“I like to define pain as an alarm system within your body. It’s designed to tell us when something is potentially wrong,” he says. “The problem is, many times pain doesn’t necessarily tell us specifically what is wrong with our body. It can only tell us that something is wrong, and that something needs our attention.”
Garvey’s patient education begins with the very first visit. His goal is to help the patient understand that much of the pain they are experiencing may be more related to their mental outlook than to their actual physical condition.
“If they have a certain belief that is not supported by evidence, sometimes changing their beliefs or changing the idea of what they’re dealing with can be profoundly impactful in changing their participation in life and what they choose to do in relation to their condition,” he says. “The more a person understands how pain works, the less pain that they have.”
Mandy Detwiler, a patient at KORT, is taking physical therapy to rehabilitate after surgery for a bulging disc in her lower vertebrae and spinal stenosis. Garvey and his team at KORT helped Detwiler to correct her posture, re-learn previously difficult everyday tasks, and most importantly, to think differently about how she experiences pain.
“Through learning about how to manage pain, and learning where pain starts and stops, I’ve been able to control it on my own,” Detwiler says. “Whereas before I might have had to rely on medication for the rest of my life.”
Cognitive behavioral therapy, which Elder uses at UK, employs some of the same precepts as Garvey’s pain education program at KORT. It involves making patients aware of how their thoughts and beliefs influence their feelings and behavior.
“We recognize that people who have chronic pain have spiraled down from a normal level of functioning into a depressed suffering state,” he says. “And we know that the chronic pain patient, their feelings are of fear and helplessness. … And they have to understand where those fears come from. Cognitive behavioral therapy helps do that.”
Murphy and Elder both say that physical therapy and cognitive behavioral therapy are under-utilized in the current health care system, for a variety of reasons. Most importantly, many of these alternative treatments are not covered by insurance. And Murphy notes that many patients using opioids for chronic pain began using them for acute pain after suffering a major injury. That initial exposure, often at high doses, makes it more difficult to transition patients to a physical therapy or cognitive behavioral therapy program, he says.
Elder strikes a hopeful tone, however. He observes that one of the major goals of the Affordable Care Act is to re-orient the compensation structure for doctors, clinics, and others in the medical community around patient satisfaction and functioning. This will eventually lead to more services like physical therapy and cognitive behavioral therapy for chronic pain being covered by insurance, he predicts.
The panelists conclude by offering hope for those persons struggling with chronic pain who may feel that their prospects for relief are threatened by the opioid epidemic. “Patients need to know that chronic pain is a legitimate condition, and that they have a right to care,” Murphy says. “They may not have a right to get opiates – that’s very selective, it’s a big deal. But, I tell you what, patients need to find people who will understand them and will take the time, and will treat them.”
“Pain is not something you have to live with,” Garvey adds. “If you have the right providers, the right caregivers who address it, not only from a pharmacological perspective but from a physical perspective – not only drugs but the body and the brain – that can change people’s lives, and it does give you hope.”