Early physical therapy (PT) may help reduce the risk of long-term opioid use by serving as an alternative or adjunct to short-term opioid use for patients with various types of musculoskeletal pain. Physicians should recognize the potential benefits of early PT for certain segments of this patient population.


 

The burden of musculoskeletal pain in the United States has been well documented, with recent estimates suggesting that it affects nearly half of all American adults. A concerning aspect of the management of musculoskeletal pain is the potential for patients to transition to chronic opioid use. “The CDC guidelines recommend non-pharmacologic pain management as first-line treatment for musculoskeletal pain,” says Eric Sun, MD, PhD. “Early use of physical therapy (PT) may be a promising non-pharmacologic strategy that improve symptoms and possibly reduce opioid use in this patient population.”

 

Taking a Closer Look

Previous studies have demonstrated a link between use of early PT and patient-reported outcomes, healthcare costs, and opioid use. However, the implications of early PT for musculoskeletal pain in the neck, knee, shoulder, and back are largely unknown. Given recent national and local initiatives by healthcare advocacy groups to curb the opioid epidemic, a broader investigation of non-pharmacologic musculoskeletal pain management is necessary.

To address this gap, Dr. Sun and colleagues had a study published in JAMA that analyzed insurance claims data on nearly 89,000 opioid-naive adults (aged 18 to 64) with a new diagnosis of musculoskeletal pain. About 29% of patients in the analysis received early PT. The goal was to determine the association between early PT and subsequent opioid use. The study focused on patients with low back, neck, knee, or shoulder pain that was severe enough to require two visits to physicians within 30 days and at least one opioid prescription during the 90 days after an initial diagnosis.

“We found that early PT was associated with a 10% decreased risk of any long-term opioid use,” Dr. Sun says. After adjusting for potential confounders, early PT correlated with a statistically significant reduction in the incidence of any opioid use between 91 and 365 days after the index date for patients with shoulder, neck, knee, and low back pain (Table). In addition, early PT was associated with a 5% to 10% reduction in oral morphine milligram equivalents (MMEs) for those with low back, shoulder, and knee pain who did use opioids. However, no such association was seen between early PT and subsequent MMEs for those with neck pain. Dr. Sun says that plans are underway to expand the current study to examine other patient populations and pain conditions.

 

Assessing Implications

“The magnitude of our study findings suggest that early PT may not only improve symptoms but could also provide mild-to-moderate protection against the risk and intensity of long-term opioid use,” says Dr. Sun. “Therefore, physicians should consider early PT an important part of the treatment armamentarium in managing pain.” In addition, it may behoove clinicians to refer patients with musculoskeletal pain to receive PT within 30 days to enhance protection against opioid use. Additional research may determine if other non-pharmacologic services can further mitigate long-term opioid use in those living with this pain.

Implementing a strategy of referring patients with musculoskeletal pain to early PT is consistent with recent clinical guidelines, but it could also play an important role in reducing risks of transitioning to chronic long-term opioid use. In future research, efforts should be made to learn more about why early PT appears to alleviate some types of musculoskeletal pain but not others. Such data would provide helpful insights into the implications of the widespread adoption of non-pharmacologic pain management strategies.

References

Sun E, Moshfegh J, Rishel CA, Cook CE, Goode AP, George SZ. Association of early physical therapy with long-term opioid use among opioid-naive patients with musculoskeletal pain. JAMA Netw Open. 2018;1:e185909. Available at: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2718095.

Liu X, Hanney WJ, Masaracchio M, et al. Immediate physical therapy initiation in patients with acute low back pain is associated with a reduction in downstream health care utilization and costs. Phys Ther. 2018;98:336-347.

Childs JD, Fritz JM, Wu SS, et al. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Serv Res. 2015;15:150.

Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain–United States, 2016. JAMA. 2016;315:1624-1645.

Volkow ND, McLellan AT. Opioid abuse in chronic pain–misconceptions and mitigation strategies. N Engl J Med. 2016;374:1253-1263.