The U.S. opioid epidemic is generally viewed as an unintended consequence of the U.S. health system’s effort to manage pain. Historically, the health system focused on controlling pain rather than eliminating it. As a result, in the 1990s, healthcare providers turned to pharmaceuticals for fast pain relief, leaving non-pharmaceutical approaches that take longer in the dust. But the resulting opioid crisis shows the U.S. health system urgently needs to transform pain management.
That shift has started. In 2016, the Centers for Disease Control and Prevention (CDC) issued guidelines for prescribing opioids for chronic pain, which is pain lasting longer than three months. The guidelines were the product of an extensive review of the best clinical evidence, input from experts, and feedback from a federal advisory committee. In the guidelines, the CDC drew attention to physical therapy as a worthwhile option to decrease prescriptions of opioids for chronic pain. The report said, “There is high quality evidence” supporting the use of physical therapy as part of a multidisciplinary chronic pain-management approach.
Physical therapists not only treat the symptoms but also address the movement patterns that cause pain. The therapy treats pain through movement, hands-on care and patient education. Therapists create individualized treatment plans, which include identifying individual risk factors for pain, to prevent future episodes. By combining a variety of therapeutic approaches, physical therapy offers a safe solution to pain management.
The longer an individual’s pain persists, the greater the chance it becomes chronic, making it harder to treat. This reality adds an extra layer of complexity to the opioid epidemic. Chronic pain requires multidisciplinary collaboration for effective reversal. There are clinical, psychological and social after effects to chronic pain, including limited mobility, depression, anxiety and loss of productivity. Early access to physical therapy can preclude a condition from becoming chronic.
But insurance barriers often get in the way. Requirements for preauthorization, high copays and limits on the number of visits restrict access to services. The Department of Health and Human Services’ (HHS) 2019 Report on Pain Management Best Practices highlights gaps in access to care for pain and inconsistencies in insurance coverage. The authors devote an entire section to restorative therapies, which supports inclusion of physical therapy in pain management. A 2018 cross-sectional study of commercial, Medicaid and Medicare Advantage health plans published in JAMA showed that although the majority of plans had coverage for physical therapy, they varied significantly in prior authorization criteria, visit limits and out-of-pocket costs. Study interviews with senior executives of various insurance plans highlighted the administrative burdens and costs associated with developing and revising coverage policies.
These articles, combined with the recent Centers for Medicare & Medicaid bulletin on Medicaid Strategies for Non-Opioid Pharmacologic and Non-Pharmacologic Chronic Pain Management, demonstrate increased recognition of the value of physical therapy and promising movement toward giving it its due as a pain-management strategy. The bulletin reminds states of the options they have for paying for physical therapy and other non-drug pain treatments.
The redesign of pain management needs to include payment models that provide incentives for a multidisciplinary approach to pain management, with early and easy access to non-drug approaches. Payers need to give providers incentives to look for non-pharmaceutical alternatives, revise coverage policies to remove access barriers and make it easy for the patient to receive services. The pain-management makeover should adopt a strategy of treating the cause of pain and move away from the strategy of the last 25 years, which focused on using meds to mask pain as a way to control it.
While attacking the root cause of the problem makes sense, it will be important to ensure this approach is effective and minimizes risk. Such evaluations too often were lacking as opioid use skyrocketed. To be sure, opioids still have a legitimate place in medicine, especially for those with serious and terminal illnesses. Pain-management transformation shouldn’t make it harder for those with such chronic pain to get the meds they need.
As we shift the pain-treatment paradigm, it will be critical to use the capabilities of firms such as Abt Associates to measure outcomes and analyze treatment models. We need to make sure pain sufferers get the right treatment to relieve their pain—whether meds or physical therapy. With better prescription practices and more emphasis on physical therapy, we can avert another epidemic that ravages individuals, families and communities.