An alternative approach to solving the opioid epidemic: is there a role for non-pharmacologic analgesic therapies?

Relationships between physical therapy intervention and opioid use: A scoping review

OBJECTIVE

To synthesize available evidence that has examined the relationship between physical therapy (PT) and opioid use. TYPE: Scoping Review LITERATURE SURVEY: Data sources including Google Scholar, Embase, PubMed, Cochrane Library, and CINAHL were searched for English articles up to October 24, 2019 using terms ("physical therapy"[Title/Abstract] OR physiotherapy[Title/Abstract] OR rehabilitation[Title/Abstract]) AND (opiate*[Title/Abstract] OR opioid*[Title/Abstract]).

METHODOLOGY

Included studies evaluated a PT intervention and reported an opioid-use outcome. Data were extracted to describe the PT intervention, patient sample, opioid-use measurement, and results of any time or group comparisons. Study quality was evaluated with Joanna Briggs checklists based on study design.

SYNTHESIS

Thirty studies were included that evaluated PT in at least one of these seven categories: interdisciplinary program (n = 8), modalities (n = 3), treatment (n = 3), utilization (n = 2), content (n = 3), timing (n = 13), and location (n = 2). Mixed results were reported for reduced opioid-use after interdisciplinary care and after PT modalities. Utilizing PT was associated with lower odds (ranging from 0.2-0.8) of using opioid medication for persons with low back pain (LBP) and injured workers; however, guideline-adherent care did not further reduce opioid use for persons with LBP. Early PT utilization after index visit for spine or joint pain and after orthopedic surgery was also associated with lower odds of using opioid medications (ranging from 0.27-0.93). Emergency department PT care was not associated with fewer opioid prescriptions than standard emergency department care. PT in a rehabilitation center after total knee replacement was not associated with lower opioid use than inpatient PT.

CONCLUSIONS

The relationship between timing of PT and opioid use was evaluated in 13 of 30 studies for a variety of patient populations. Eight of these 13 studies reported a relationship between early PT and reduced subsequent opioid use, making the largest sample of studies in this scoping review with supporting evidence. There is limited and inconclusive evidence to establish whether the content and/or location of PT interventions improves outcomes because of heterogeneity between studies.

Veterans Team Recovery Integrative Immersion Process (Vet TRIIP): A Qualitative Evaluation of Participation and Impact

INTRODUCTION

The Veterans Team Recovery Integrative Immersion Process (Vet TRIIP) is a short-term multi-modality complementary, integrative immersion program for veterans with chronic pain, post-traumatic stress, and related symptoms. Geared toward Veterans, active duty servicemembers, family members, and caregivers, Vet TRIIP aims to honor and empower them to create healthy, happy, and productive civilian lives. This study evaluates the program to determine its impact on the quality of life and ways to improve and develop Vet TRIIP.

MATERIALS AND METHODS

In total, 14 clients participated in the qualitative review of the Vet TRIIP program in San Antonio. The participants were interviewed related to their reason for participating, their most bothersome symptoms and the effects of Vet TRIIP on those symptoms, service provided that is most and least appreciated, suggestions for improvement, and things learned from Vet TRIIP that helped them daily. Responses were analyzed for emerging themes.

RESULTS

The main reasons for participating were physiological and psychological needs, social support, and curiosity to address their reported symptoms such as pain, stress/anxiety, and depression. Vet TRIIP reportedly improved their quality of life and decreased stress. The participants liked most the support of the Vet TRIIP staff and the interventions such as reiki and massage. Other participants did not like acupuncture. Participants suggested the addition of professional psychological services could be helpful. They reported that emotional freedom technique (EFT/tapping) and guided breathing were most useful in their daily lives. Each participant reported that Vet TRIIP was a positive experience that helped with their pain, anxiety, and stress management, providing an improvement in their quality of life. It also imparted an eye-opening experience to nontraditional non-pharmacological interventions for pain, anxiety, and stress.

CONCLUSIONS

Evaluative studies on organizations that support Veterans are useful to gauge the effectiveness and impact. Through this study, Veterans expressed perceived strengths and weaknesses of the program so further development and appropriate services will be provided. Similar studies on the impact of non-profit organizations are encouraged. Vet TRIIP significantly impacts the lives of many through stress and pain reduction, potentially preventing suicide.

Long-Term Multicolumn-Lead Spinal Cord Stimulation Efficacy in Patients with Failed Back Surgery Syndrome: A Six-Year Prospective Follow-up Study

OBJECTIVE

The use of multicolumn-lead spinal cord stimulation (SCS) to control back pain (BP) and leg pain (LP) in patients with failed back surgery syndrome (FBSS) in the short term and mid-term has been well documented. Our study investigated whether SCS remained efficient after 72 months.

METHODS

In an observational, single-center study, we assessed SCS efficacy in 62 patients with FBSS patients. BP, LP, and magnitude of daily activity limitation (DAL) were graded using a 0-10 visual analog scale (VAS) preoperatively and at 2, 6, 12, 24, 36, and 72 months after SCS implantation. Sleep quality, use of medications, and complications were also recorded.

RESULTS

Of the 62 patients, 15 with complete follow-up data available were still using their SCS device at 72 months (SCS+). For these patients, the VAS scores for BP, LP, and DAL had changed from a median of 9 (interquartile range [IQR], 8.5-10), 7 (IQR, 6-8), and 8 (IQR, 8-9) preoperatively to a median of 4 (IQR, 3-4.5), 3 (IQR, 1.5-3.5), and 3 (IQR, 2-4) at 72 months. Their quality of sleep and analgesic medication consumption had also improved. In a subset of patients no longer using the SCS device after 72 months (SCS-), the VAS scores for BP, LP, and DAL, quality of sleep, and medication consumption were comparable to those for the SCS+ group. The SCS- group was less satisfied with the technique and were less professionally active than were the SCS+ group.

CONCLUSIONS

The SCS device provides sustained beneficial effects on BP, LP, DAL, sleep, and medication consumption in patients with FBSS still using it at 72 months postoperatively. Further studies are needed to identify the factors of adherence to the technique and the chances of success compared with the natural evolution of FBSS.

Opioid free onco-anesthesia: Is it time to convict opioids? A systematic review of literature

The epidemic of opioid crisis started getting recognised as a public health emergency in view of increasing opioid-related deaths occurring due to undetected respiratory depression. Prescribing opioids at discharge has become an independent risk factor for chronic opioid use, following which, prescription practices have undergone a radical change. A call to action has been voiced recently to end the opioid epidemic although with the pain practitioners still struggling to make opioids readily available. American Society of Anesthesiologist (ASA) has called for reducing patient exposure to opioids in the surgical setting. Opioid sparing strategies have emerged embracing loco-regional techniques and non-opioid based multimodal pain management whereas opioid free anesthesia is the combination of various opioid sparing strategies culminating in complete elimination of opioid usage. The movement away from opioid usage perioperatively is a massive but necessary shift in anesthesia which has rationalised perioperative opioid usage. Ideal way moving forward would be to adapt selective low opioid effective dosing which is both procedure and patient specific while reserving it as rescue analgesia, postoperatively. Many unknowns persist in the domain of immunologic effects of opioids, as complex interplay of factors gets associated during real time surgery towards outcome. At present it would be too premature to conclude upon opioid-induced immunosuppression from the existing evidence. Till evidence is established, there are no recommendations to change current clinical practice. At the same time, consideration for multimodal opioid sparing strategies should be initiated in each patient undergoing surgery.