In its final version of guidelines for prescribing opioids for chronic pain, the US Centers for Disease Control and Prevention (CDC) minces no words about the importance of physical therapy and other nondrug/nonopioid approaches, and delivers a clear message that physical therapists (PTs) and physical therapist assistants (PTAs) have known for some time: there are better, safer ways to treat chronic pain than the use of opioids.
Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain,” the CDC states in its first recommendation. “The contextual evidence review found that many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, psychological therapies such as [cognitive behavioral therapy, or CBT], and certain interventional procedures can ameliorate chronic pain.”
The CDC guidelines were created in response to growing rates of opioid use disorder and opioid overdose, a problem fueled by ever-increasing rates of opioid prescriptions written by primary care providers—approximately 259 million prescriptions written in 2012 alone. In its introduction to the guideline, CDC cites from 1 study that among 15- 64-year-olds who received opioids for noncancer pain, 1 in 550 died from an opioid-related overdose at a median of 2.6 years from their first prescription.
A draft version of the guidelines were published in late 2015 as part of a CDC call for comments. APTA responded with strong support for the recommendations, writing that approaches such as physical therapy “have been underutilized, and, therefore, can serve as a primary strategy to reducing prescription pain medication abuse and improving the lives of individuals with chronic pain.”
Other stakeholders were less enthusiastic. According to a report from National Public Radio, some critics questioned the CDC recommendation against using opioids as a first-line treatment for chronic pain.
In that NPR report, Debra Houry, director of CDC’s National Center for Injury Prevention and Control, responded by pointing to weak evidence supporting the benefits of opioids for chronic pain and growing evidence pointing to the risks. “We have decided that because of that, and the uncertain benefits of opioids, that continuing to prescribe them for chronic pain is not warranted,” Houry said. “On the other end, nonopioids, there is evidence for their benefits.”
In addition to the statement around first-line treatment, the CDC guideline includes recommendations that address the importance of establishing treatment goals, discussing risks of opioids with patients, choosing appropriate dosage and release factors, and conducting thorough follow-up assessments once a patient has been prescribed an opioid. The guidelines are not intended to apply to opioid use related to patients with cancer, palliative, or end-of-life care.
News of the CDC guidelines spread quickly, with major media outlets including Newsweek,USA Today, The Wall Street Journal, and others reporting on the recommendations that arrive amidst increased national attention on the epidemic of opioid abuse and heroin use across the country. APTA is participating in a White House initiative to address the problem through, among other things, increased public awareness.
Those APTA public awareness efforts includea page on MoveForwardPT.com, the association’s website for consumers looking for information on physical therapy, with information on the risks of opioids and physical therapy’s role in the treatment of pain.
In addition to the guideline, CDC also released a checklist and fact sheet that outline the basics of the larger document. Both stress that nonopioid therapies should be “tried and optimized” before considering an opioid prescription as well as during reassessment of a patient who has received a prescription for opioids.