Read the rest of Tonic's opioid coverage here.
It could have started with something mundane. A broken toe. A bad knee. Back problems. It could end in a full-time heroin addiction, you sitting numbly in your basement endlessly re-watching DVDs, or in an ambulance with a dose of Narcan in your system.
The seemingly innocuous treatment of chronic pain with painkillers that began in the late 1990s has spiraled out of control. In 2016, the opioid epidemic killed a record 33,000 people. The lion's share of those deaths weren't from heroin or street fentanyl, but legally prescribed painkillers. The race is on to find alternatives, and physical therapy has recently come into focus as an effective challenger to opioids, though switching from a pill-first mentality isn't easy.
A pill is quick and simple: Unscrew the cap, pop it in, and wait for the comfort to wash over you. What's not easy are squats with a bad knee. With physical therapy, you have to get off of work early, drive to the appointment, sweat and strain for an hour or so, and then be sore for days. It's no surprise many choose the first alternative, even if it's the second that they really need.
One of the ironies of opioid pills is that they don't really help with pain like people think they do. While sales of prescription opioids have nearly quadrupled since 1999 to 2014, there hasn't been an overall change in the amount of pain Americans report. That's because "opioids are only designed to work in the acute period of pain," says Rachel Noble, a Maryland-based therapist and director at Advantia Mental Wellness. "[Opioids] are not designed to be taken in the long run." In fact opioids taken over time actually make pain worse, she adds.
Instead of addressing the root of the pain as physical therapy does, opioids mask symptoms, which then linger and become chronic pain—pain that lasts longer than 12 weeks. The longer pain lasts, the more opioids you take, Noble says. Tolerance increases incrementally until you're taking ludicrous dosages, such as the case of one "little old lady" who came to Noble's office "on enough opioids to take down an elephant."
The masking of chronic pain with opioids begins to spread beyond the physical and into the social realm. "They don't go to birthday parties, don't get in the car [because of the pain.] They just start to isolate," Noble says. Those in chronic pain are "less likely to mow the lawn or help with groceries. Relationships get very lopsided and the people who become the caregivers become very strained."
Eventually isolation can set in along with a sense of depression and the feeling their lives are devoid of meaning. Noble had one patient who, "by the time he made it in[to my office] was isolated from his family and was re-watching 1970s concerts in his basement over and over again."
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Nobel emphasizes that those suffering from chronic pain, "don't take [opioids] to get high." Rather they take them to function, and sometimes in the most basic sense of the word.
The transition from painkiller to street drug is insidiously gradual. Doctors, fearing their patients will or are developing addictions, may cut their patients off opioids but won't give them a good alternative for their pain. Still suffering, patients sometimes go "doctor shopping" looking for physicians who will fill opioid scripts. If that fails, they may go to the ER for relief. But after enough visits they can get flagged as "drug seeking" in the computer system. Some wander out of the hospital, still in pain. Luckily there's a guy on the corner hawking the ugly, cheaper sister of opioid pills: heroin.
"When you drive down the street in Baltimore at night," Noble says "[Dealers] come knock on your window and offer you heroin for five dollars."
Fentanyl, 50 times stronger than heroin, can be cheaper still. Joseph Brence, spokesperson for the American Physical Therapy Association, says that while "the pill is going to be the cheaper option immediately, physical therapy is cheaper in the long run." You need more opioids as tolerance builds, and while opioids mask the symptom, they do nothing to help rebuild muscles and mobility. For that, you need something like physical therapy.
In March 2016, the Center for Disease Control and Prevention (CDC) toted physical therapy under its new guidelines for managing chronic pain. Also in 2016, the American Physical Therapy Association issued a widespread ad campaign in collaboration with the Obama administration to raise awareness about the dangers of opioids and the availability of alternatives. But changing the allure of a pill has been difficult.
Physical therapy is trickier to apply than a script—it requires the patient to take an active role in their own recovery. Though that may not always happen. Home exercise programs (HEP) is the "homework" physical therapy patients often have to do outside of their appointments. Unfortunately, patients may not be doing their HEP correctly, for the right amount of time, or at all—especially if they don't have someone around to hold them accountable. Their recovery times could be longer, their costs greater, or their faith in physical therapy damaged.
PhysHome, a Turkish tech startup, is trying to get around this by providing physical therapists a magic window to "peek in" on patients' HEP routines. They provide a system where patients can wear sensors that tell them when they are doing exercises correctly and relay the data to their physical therapist who can track their performance remotely. If there's a problem, therapists can correct the patient's form at the next appointment.
Patients have to put work into their physical therapy, but the work pays off even if it's a delayed sense of gratification. And then opioids can potentially be cut out of the recovery process almost entirely. In 2016, former volleyball star, Gabrielle "Gabby" Reece—an advocate for non-opioid pain relief—had her knee replaced. She said no to opioids and instead chose to rely exclusively on physical therapy for her recovery.
"I didn't want to mess around with [opioids]," Reece tells me. "High IQ or low, old or young, Christian or Muslim, strong or not, I knew people who were really taken down by this stuff… I knew a lot of athletes that went in [for an injury] and ended up coming out with a really serious painkiller problem."
To clarify, Reece was given Tramadol (a synthetic opioid) right after her surgery to help manage the acute pain. But after preliminary period, she went ahead without painkillers. Even though she had more high-power painkillers within arms' reach in her recovery room, she didn't touch them. "It's sort of like when you go to dinner—you decide whether to eat from the breadbasket or not." She'd decided ahead of time: no breadbasket.
Reece doesn't deny that recovery was painful. But she also says it wasn't like she was sitting there biting down on a piece of cloth like during an old-school amputation. You don't have to be Wonder Woman, or Gabby Reece, to be able to recover without opioids. Choosing alternative pain management strategies is becoming more common as patients, doctors, and the medical system as a whole begin to confront the dangers of opioid use beyond acute pain.
"I want to stay compassionate. Pain is personal," Reece says. What works for one person may not work for another, and pain varies from person to person. Her message is not simply to "tough it out." But she emphasizes that reaching for a quick-fix pill is not the answer. "We know how that story ends."
Update: A previous version of this story inaccurately stated that in 2016, the opioid epidemic killed "a record 50,000 people," and has been changed to "33,000."
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