tag:theconversation.com,2011:/us/topics/opioid-series-2017-55326/articlesOpioid series 2017 – The Conversation2019-09-04T11:52:54Ztag:theconversation.com,2011:article/1191482019-09-04T11:52:54Z2019-09-04T11:52:54ZAn opioid success story: Efforts to minimize painkillers after surgery appear to be working<figure><img src="https://images.theconversation.com/files/290207/original/file-20190829-106512-1ydlodk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many hospitals are implementing new procedures to replace prescribing opioids after surgery. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/urgent-surgery-professional-smart-intelligent-surgeons-1062215336?src=-1-28">Dmytro Zinkevych/Shutterstock.com</a></span></figcaption></figure><p>The opioid epidemic has been wreaking misery and death across the nation for years. In 2017 alone, opioid overdoses killed more than <a href="https://www.cdc.gov/drugoverdose/data/index.html">47,000 people</a> – <a href="https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812603">10,000 more deaths</a> than were caused by traffic accidents that year. </p>
<p>For many people who abuse opioids, the problem begins with opioid prescriptions from their doctors for pain relief. Government data show that <a href="https://www.ncbi.nlm.nih.gov/pubmed/25785523">21%-29% of patients</a> who are prescribed opioids go on to misuse them, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/25785523">8% to 12% develop an opioid</a> abuse disorder. From 2016-2017, <a href="https://www.hhs.gov/opioids/sites/default/files/2018-09/opioids-infographic.pdf">800,000 people used heroin</a> for the first time, according to the U.S. Department of Health and Human Services, with <a href="https://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm">80% starting</a> with prescription drugs. </p>
<p>Many hospitals have begun to take steps to minimize the amount of opioids prescribed after surgery by managing pain through alternative methods. Research suggests that these programs can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5943369/">reduce the need for opioids after surgery</a> and can reduce both post-surgical complications and the average length of hospital stay. </p>
<p>At Keck Medicine at the University of Southern California, I’m the director of our program to reduce opioid prescriptions and manage pain in other ways. I have spent the past year leading our enhanced recovery team to design and implement various pathways that have significantly reduced the opioid burden in our surgical patients. Here’s how these programs look in practice.</p>
<h2>New practices, less pain</h2>
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<img alt="" src="https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Making sure that patients are hydrated after surgery is an important part of pain management.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/selective-focus-orange-juice-bottle-blurry-1441467887?src=-1-3">Komsan Loonprom/Shutterstock.com</a></span>
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<p>We have modeled our program to manage pain after others that were developed originally to improve outcomes and shorten hospital stays after colorectal surgery. These programs, called Enhanced Recovery After Surgery, or ERAS, involve a range of measures, such as employing many different ways to reduce pain, and early mobility.</p>
<p>We have found that these protocols are easy to enact and can be as simple as giving the patients non-narcotic pain relievers in the days leading up to surgery to prep the body prior to surgery.</p>
<p>Some of the other methods include:</p>
<ul>
<li>Ensuring the patients and their families have clear understanding and expectations about post-surgical pain management</li>
<li>Making sure a patient has plenty of fluids and carbohydrates</li>
<li>Using a nerve block during surgery </li>
<li>Encouraging the patient to get up and walking within a day after surgery</li>
<li>Sending the patients home with no opioid prescriptions, or with a prescription for a very small number of pills. </li>
</ul>
<p>We have partnered with clinicians across the health care continuum. The process involves physicians, nurses, physical therapists, occupational therapists, case management, nutrition, pre-op management and social work. </p>
<p>While we have not yet published the results of our programs in an academic journal, I can say that these practices produced very tangible results; the post-operative opioid usage decreased by 50% in our division of thoracic surgery and by 60% in our department of urology.</p>
<p>The hospital’s division of cardiac surgery also reduced the use of post-operative opioid use by 45% for patients undergoing minimally invasive valve-replacement procedures. We anticipate publishing data on this finding as well. Some of our patients have gone through pre-op, surgery and post-operative care without the use of opioids at all and without any undue pain.</p>
<p>Other hospitals have reported success, too. </p>
<p>The <a href="https://www.modernhealthcare.com/care-delivery/hospitals-look-cut-opioids-surgery-and-beyond">University of Pittsburgh Medical Center</a> cut the number of post-surgical opioid prescriptions in half. </p>
<p>A <a href="https://www.wsj.com/articles/the-push-for-fewer-opioids-for-new-mothers-11559554201">Cleveland Clinic</a> pilot program to reduce opioid prescriptions in new mothers following Cesarean sections immediately reduced opioid use by two-thirds, and opioid-free hospital stays more than tripled. </p>
<p>A year after the <a href="https://www.ncbi.nlm.nih.gov/pubmed/29510097">University of Virginia</a> implemented its ERAS protocol for patients undergoing thoracic surgery, it reduced the use of post-surgical morphine equivalents by more than half, reduced length of stay by two days, and even cut hospital operating costs.</p>
<p>These practices go beyond minimizing opioid prescriptions and can contribute to better overall patient care. For example, at Keck Medicine, our preliminary results show that we have been able to decrease the length of patient stay by up to 21% and have reduced complications from <a href="https://www.heart.org/en/health-topics/atrial-fibrillation/what-is-atrial-fibrillation-afib-or-af">atrial fibrillation</a>, or irregular heart beats that can lead to stroke, blood clots and heart failure, in thoracic surgery to less than 10%. We have also decreased intensive care stay for head and neck surgery by as much as one day. Also, we have cut by two days the length of time that catheters need to remain inserted into the bladders of post-operative urological patients. This is important because the <a href="https://www.emedicinehealth.com/foley_catheter/article_em.htm#foley_catheter_risks">risk of infection increases</a> the longer a catheter remains inserted.</p>
<h2>Advocating for patients</h2>
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<img alt="" src="https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Consulting with patients before surgery can help them understand how to deal with post-surgical pain in different ways.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-patient-having-consultation-doctor-office-317573702?src=-1-10">Monkey Business Images/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>An integral piece of the success is patient education. Most patients are so overwhelmed when they are about to undergo surgery and may be unaware that there are procedures to help limit opioid usage. And those who hear about opioid-minimizing practices may fear potential post-operative pain and may not consider that option. </p>
<p>It is important to educate patients well before their surgeries so they know their expected level of pain after their surgery and the different medication and procedures in place to minimize that post-operative pain. This kind of education is key in empowering patients to make informed decisions regarding opioids and their health.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/119148/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Kim works for Keck USC School of Medicine. </span></em></p>About 1 in 4 people prescribed an opioid for pain end up abusing it. New methods to reduce the need for opioids after surgery have been shown to work – and thus minimize the need for such drugs.Michael Kim, Clinical Assistant Professor of Anesthesiology, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/991192018-07-20T10:37:10Z2018-07-20T10:37:10ZNaloxone remains controversial to some, but here’s why it shouldn’t be<figure><img src="https://images.theconversation.com/files/228088/original/file-20180717-44076-1o1bibp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">U.S. Surgeon General Dr. Jerome Adams demonstrates the proper procedure for administering a nasal injection of naloxone on reporter Jennifer Lott, left, during a visit to the University of Mississippi Medical Center in Jackson, Miss., May 17, 2018. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/search?st=mr&reference=9a6a09cf2c1d4c88b42cfb39555491b3">AP Photo/Rogelio V. Solis</a></span></figcaption></figure><p>The overdose-reversing drug naloxone <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm">saves thousands of lives</a> each year and is <a href="https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf">more widely available</a> today than ever. So why do overdose deaths across the U.S. <a href="https://www.cdc.gov/media/releases/2018/p0329-drug-overdose-deaths.html">continue to rise</a>?</p>
<p>According to one 2018 <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3170278">study</a>, naloxone itself is partly to blame. Naloxone, the authors of the study wrote, increases opioid use and does not reduce opioid-related mortality overall because it provides users with a “safety net” and thus encourages riskier drug use. The paper set off a Twitterstorm and <a href="https://www.theatlantic.com/health/archive/2018/03/moral-hazard-opioid/555389/">controversy</a> even among those who don’t air their disagreements digitally. </p>
<p>From the perspective of a <a href="https://profiles.ucsf.edu/cyrus.ahalt">public health researcher</a>, I can say the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4584734/">weight of evidence</a> suggests that naloxone, which is often sold as the brand name Narcan, is a vital tool in fighting the overdose epidemic and, in fact, is too often not available where it is needed most. </p>
<h2>Scant evidence of moral hazard</h2>
<p>The “<a href="https://economictimes.indiatimes.com/definition/moral-hazard">moral hazard</a>” discussed in this study is an economic term, not an ethical one. It describes increasingly risky behavior in response to policies or innovations that lessen associated consequences. An example? Driving more recklessly with auto insurance than without.</p>
<p>The authors infer increased risk-taking based on trends such as ER use, crime and death, that they otherwise cannot explain. They marshal a few journalistic accounts of parties where users intentionally overdose and revive each other with naloxone. They also cite a health risk behavior literature describing increased sexual risk taking in response to anti-retroviral treatment.</p>
<p>But harm reduction experts <a href="https://www.thefix.com/narcan-party-hysteria-puts-value-drug-users-lives">have said</a> that journalistic accounts of “Narcan parties” are inaccurate and public officials who have warned of their danger acknowledge, on follow-up, that the <a href="https://theoutline.com/post/1964/narcan-parties-heroin-overdoses?zd=3&zi=inblzavm">parties are urban legend</a>. </p>
<p><a href="https://jamanetwork.com/journals/jama/fullarticle/199091">Other studies</a> of increased sexual risk behavior in response to anti-retroviral treatment conclude that this is a patient-education problem. In fact, though the relevant research on naloxone is limited, <a href="https://www.ncbi.nlm.nih.gov/pubmed/16956873">the</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2570543/">few</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/19268564">studies</a> that have been conducted echo the anti-retroviral literature in emphasizing education as critical to <a href="https://www.bmj.com/content/346/bmj.f174">achieving harm reduction</a>. Providing education and training alongside naloxone <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3163671/">improves users’ ability</a> to accurately identify and <a href="https://www.tandfonline.com/doi/full/10.1080/08897077.2015.1110550?src=recsys">confidently respond</a> to overdoses. But <a href="https://www.tandfonline.com/doi/full/10.1080/08897077.2015.1010032?src=recsys">more research is needed</a> to ensure that the overdose education and naloxone distribution model achieves harm reduction beyond reversing overdoses.</p>
<h2>Problems with naloxone availability</h2>
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<img alt="" src="https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In this Jan. 23, 2018, photo, Leah Hill, a behavioral health fellow with the Baltimore City Health Department, wears a shirt advertising the health department’s opioid overdose awareness efforts.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Crisis-Overdose-Drug/c36205905ce94b3cbc1c5638cab3f320/4/0">AP Photo/Patrick Semansky</a></span>
</figcaption>
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<p>The moral hazard study also assumes that naloxone is widely available in states that have passed naloxone laws allowing broader distribution. Yet there is evidence that access often remains critically limited despite these laws. New Hampshire’s <a href="https://anyoneanytimenh.org/">Anyone Anytime</a> program, for example, provides a wealth of resources but <a href="https://ndews.umd.edu/sites/ndews.umd.edu/files/marsch-ndews-webinar-slides-nh-hotspot-09-11-17.pdf">the drug is still often not on hand</a> because “consumers report significant barriers to access … high cost, fear of police, fear of stigmatization, lack of knowledge, fear of withdrawal. Responders report mixed feelings about making it available to the public.”</p>
<p>After Ohio <a href="http://pharmacy.ohio.gov/Pubs/NaloxoneResources.aspx">passed its naloxone law</a> in 2014, overdose deaths <a href="https://www.cincinnati.com/story/news/2017/08/30/ohio-drug-overdose-deaths-more-than-double-thanks-fentanyl/618778001/">surged</a>. But the Cuyahoga County Sheriff’s and Cleveland Police departments did not start carrying naloxone until <a href="https://www.cleveland.com/metro/index.ssf/2017/08/cuyahoga_county_sheriffs_offic_2.html">mid-2017</a>, and as the Cleveland Plain Dealer <a href="https://www.cleveland.com/healthfit/index.ssf/2018/04/life-saving_overdose_antidote.html">reported</a> as recently as April 2018, “Narcan should be available across northeast Ohio, but it’s not.” A <a href="https://www.tandfonline.com/doi/full/10.1080/08897077.2015.1132294?src=recsys">recent study</a> in Ohio found persistent barriers to naloxone distribution similar to those experienced in New Hampshire, including cost, stigma and legal fears. </p>
<p>The law enforcement community concurs. Though many states had passed naloxone laws, a 2017 Police Executive Research Forum <a href="http://www.policeforum.org/assets/opioids2017.pdf">report</a> underscored the persistent need for greater distribution. The first of its “10 Actions Police Chiefs and Sheriffs Can Take” read: “Equip officers with naloxone.” That report went further, arguing that naloxone should be distributed as broadly as possible, including to the general public: “Police chiefs and sheriffs also can use their positions of leadership in the community to call for widespread distribution of naloxone … at drug treatment facilities, homeless shelters, and other locations.”</p>
<h2>The real hazard: Fentanyl</h2>
<p>There is a better explanation for the continued rise in overdose deaths, and I believe it suggests that naloxone should be far more widely distributed.</p>
<p>From 2013 to 2016 – when most <a href="https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf">states passed naloxone laws</a> – fentanyl seizures at the border <a href="https://www.hsgac.senate.gov/imo/media/doc/Owen%20Testimony.pdf">rose astronomically</a>. In 2017, nearly 1,800 pounds were seized. To put that in perspective, consider that a <a href="https://www.statnews.com/2016/09/29/why-fentanyl-is-deadlier-than-heroin/">lethal dose</a> weighs 2 milligrams. By then, fentanyl was already the drug <a href="https://jamanetwork.com/journals/jama/article-abstract/2679931?redirect=true">most commonly involved</a> in overdose deaths. </p>
<p>The study’s authors assert that “broadening naloxone access increased the use of fentanyl.” But <a href="https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2017/research-use-misuse-fentanyl-other-synthetic-opioids">evidence</a> suggests that fentanyl deaths commonly occur among unknowing users because heroin and other drugs are easily and often <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6533a2.htm">adulterated</a> with cheaper, more potent fentanyl. The <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6533a2.htm">Centers for Disease Control and Prevention</a> notes that fentanyl follows the supply of white powder heroin in the U.S. precisely because it can be easily concealed and passed off as pure heroin. As a result, fentanyl is far less common in states, such as California, where black tar or brown powder heroin are predominant. </p>
<p>Indeed, the federally funded Fentanyl HotSpot <a href="https://ndews.umd.edu/sites/ndews.umd.edu/files/marsch-ndews-webinar-slides-nh-hotspot-09-11-17.pdf">study describes</a> the drug’s rise as a supply issue: “Consumers report buying any opioid that is available from their dealer, and widely acknowledge that fentanyl-laced heroin is most available.” </p>
<p>These perspectives from people on the ground – users, first responders and others – are particularly critical to understanding the complex relationships between fentanyl, naloxone and drug use behavior because secondary data on fentanyl are <a href="https://jamanetwork.com/journals/jama/article-abstract/2679931?redirect=true">unusually</a> <a href="https://www.theatlantic.com/health/archive/2018/05/americas-opioid-crisis-is-now-a-fentanyl-crisis/559445/">unreliable</a>. That is why the authors of the “moral hazard” study cannot control for it. Instead, their claim that moral hazard is driving fentanyl use is an inference, one that dangerously belies the fact that naloxone has not been widely distributed in many places - like New Hampshire and Cuyahoga County, Ohio - where overdose deaths continue to rise.</p>
<h2>Missed opportunity</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Narcan package. Many states report a shortage or difficulty obtaining the drug.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/may-26-2017ogden-utah-usa-naloxone-648230575?src=Hf4hNNIhEJEhuObQuW7feg-1-0">PureRadiancePhotos/Shutterstock.com</a></span>
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<p>A few public officials, like Maine’s Governor <a href="https://www.pressherald.com/2018/01/28/maine-falls-behind-other-states-in-efforts-to-prevent-overdose-deaths/">Paul LePage</a>, believe that naloxone does not, on balance, benefit society. But naloxone skepticism is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3008773/">rare among experts</a>. No professional organization has taken the position that distribution should be limited in order to prevent riskier drug use. The <a href="https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/16/13/08/reducing-opioid-overdose-through-education-and-naloxone-distribution">American Public Health Association</a> and the <a href="https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html">U.S. surgeon general</a> have issued unambiguous statements in support of naloxone’s broadest possible use.</p>
<p>Naloxone is not itself the answer to the country’s drug crisis. Nor can making it so widely available be achieved without <a href="https://www.washingtonpost.com/news/to-your-health/wp/2017/06/28/a-council-members-solution-to-his-ohio-towns-overdose-problem-let-addicts-die/?utm_term=.db0f527bc023">costs</a> – from the financial cost of Narcan kits to an increased burden on emergency services to the psychological toll that reviving the same person time and again can exact on responders. </p>
<p>Undoubtedly, another cost is that some users will use naloxone as a “safety net.” But it remains a powerful public health tool. It saves hundreds of lives every day and, if distributed with appropriate education and training, has the potential to save many thousands more. The research needed now would identify strategies to mitigate those costs and to distribute naloxone as widely as possible.</p><img src="https://counter.theconversation.com/content/99119/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cyrus Ahalt does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>One study argues that naloxone increases opioid use because it protects against death from overdose. But a closer analysis shows Narcan is the number one public health tool to fight the overdose epidemic.Cyrus Ahalt, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/921692018-06-22T10:30:12Z2018-06-22T10:30:12ZPhysical therapy could lower need for opioids, but lack of money and time are hurdles<figure><img src="https://images.theconversation.com/files/223647/original/file-20180618-85825-3o79th.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Physical therapists Steven Hunter and Laura Hayes teach an unidentified patient lumbar stabilization exercises at the Equal Access Clinic in Gainesville, Florida</span> <span class="attribution"><span class="source">Maria Belen Farias, UF Health Photography</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Physical therapists help people walk again after a stroke and recover after injury or surgery, but did you know they also prevent exposure to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393575/">opioids</a>? This is timely, given we are in a <a href="https://www.whitehouse.gov/briefings-statements/president-donald-j-trump-taking-action-drug-addiction-opioid-crisis/">public health emergency</a> related to an opioid crisis.</p>
<p>Many people addicted to opioids are <a href="https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use">first exposed</a> through a medical prescription for pain. Opiate-based drugs provide relief for acute conditions, such as post-surgical pain. </p>
<p>Unfortunately, the effectiveness of opioids decreases after time, requiring <a href="https://www.ncbi.nlm.nih.gov/pubmed/29796831">higher doses of the drug for the same effects</a> and, perhaps counter-intuitively, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29796831">worsening pain in some people</a>. Many people progress from this prescription to other opiate derivatives, including heroin and fentanyl. As a result, a growing emphasis has been placed on nonpharmacological alternatives to opioids.</p>
<p>I am a physical therapist and I have studied non-pharmacological methods of preventing the transition from acute to chronic pain. It’s an exciting time for the field, because practice and research are showing that physical therapy could diminish the need for opioids, and thus lower the risk of addiction.</p>
<h2>Reducing initial exposures to opioids</h2>
<p>Part of the proposed solution to the opioid crisis is to limit new opioid exposures. Physical therapists are an important part of this process. And it is not just physical therapists who are saying this. </p>
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<img alt="" src="https://images.theconversation.com/files/223651/original/file-20180618-85834-bvx501.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/223651/original/file-20180618-85834-bvx501.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/223651/original/file-20180618-85834-bvx501.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/223651/original/file-20180618-85834-bvx501.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/223651/original/file-20180618-85834-bvx501.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/223651/original/file-20180618-85834-bvx501.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/223651/original/file-20180618-85834-bvx501.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">Mindy Miller/University of Florida Photography</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>A <a href="https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf">letter to the president</a> from the Commission on Combating Drug Addiction and the Opioid Crisis stated, “individuals with acute or chronic pain must have access to non-opioid pain management options. Everything from physical therapy, to non-opioid medications, should be easily accessible as an alternative to opioids.” U.S. Surgeon General Jerome Adams echoed this <a href="http://www.arkansasonline.com/news/2018/apr/13/surgeon-general-speaks-on-state-opioid--1/">call for alternative treatments</a>, including physical therapists. </p>
<p>The Centers for Disease Control and Prevention also issued <a href="https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm">prescribing guidelines</a> in 2016 that recommend physical therapists be considered a first-line treatment for people with chronic pain conditions. </p>
<p>Research supports these positions, including research papers studying opioid use for common musculoskeletal pain conditions like <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393575/">back</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29073739">knee</a> and <a href="http://mcpiqojournal.org/article/S2542-4548(17)30057-7/fulltext">neck pain</a>. </p>
<p>These studies show quite convincingly that the probability of receiving a prescription for opioids is <a href="https://www.ncbi.nlm.nih.gov/pubmed/29790166">89 percent lower</a> for people seeing a physical therapist for pain. Seeing the physical therapist sooner, rather than later, makes this protective effect even <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393575/">greater</a>. </p>
<h2>Why don’t more people see a physical therapist?</h2>
<p>People in pain can go <a href="http://www.apta.org/StateIssues/DirectAccess/">directly to a physical therapist</a> in every state. So why don’t more people to do this? The simple answer: time and money.</p>
<p>Steven George, the director of musculoskeletal research for the Duke Clinical Research Institute, recently wrote, “Our existing health care system is designed to treat pain through <a href="http://thehill.com/business-a-lobbying/358037-our-inability-to-adequately-treat-pain-has-caused-tremendous-societal">easily delivered products, like opioids, injections and surgery,</a>” suggesting that alternatives are not as easily delivered.</p>
<p>Only about <a href="https://www.ncbi.nlm.nih.gov/pubmed/28441685">10 percent</a> of people who see a physician for back pain get referred to a physical therapist. Only <a href="https://www.ncbi.nlm.nih.gov/pubmed/29180553">37 percent</a> of those people actually go. The process to make an appointment can be lengthy and time-consuming, and insurance companies often slow down the process. Some <a href="https://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/hmo/how-do-referrals-work-in-my-hmo-plan.html">HMO insurance plans</a> require that physical therapy treatment be certified as medically necessary, or they will not pay. And, there’s another step: pre-authorization. This, too, delays the access to covered care even more. For a person in pain and in need of help, this is a deterrent. It’s much easier to ask for a pill. </p>
<p>Then there is the cost. Physical therapists are often classified as specialists, so co-payments may be as high as <a href="https://www.aetna.com/sbcsearch/getmysbc?T=1410822&D=01-01-2017">US$75 a visit</a>. The average patient with back pain sees a physical therapist for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393575/">seven visits</a>. Even with insurance coverage, this episode of care still will cost the person over US$500 out of pocket compared to the cost of a single primary care visit and prescription. Several states, including <a href="http://www.apta.org/Media/Releases/Legislative/2011/3/17/">Kentucky</a>, have enacted laws limiting co-payment for many services. One of the recommendations from the President’s Commission was that alternatives to opioids, including physical therapy, should be adequately covered by payers. These recommendations have yet to be acted upon.</p>
<p>So what does all of this mean for people in pain? First, seeing a physical therapist is effective for many pain conditions. Second, getting to a physical therapist sooner rather than later decreases the use of opioid medication. The current health care system must change in order for people in pain to access this safe and effective non-opioid alternative for pain management.</p><img src="https://counter.theconversation.com/content/92169/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Bishop works for University of Florida Department of Physical Therapy.
Mark receives funding from the National Institutes of Health to study conservative interventions for pain.
He serves on the Board of Directors of the Florida Physical Therapy Association. </span></em></p>As the nation grapples with its opioid addiction epidemic, one solution for many with chronic joint pain and back pain could be physical therapy. But it’s often underutilized. Here’s why.Mark Bishop, Associate Professor of Physical Therapy, University of FloridaLicensed as Creative Commons – attribution, no derivatives.