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The “Opioid Crisis” - Masking the Real Crisis of Chronic Musculo-Skeletal Pain


The Opioid crisis

The opioid crisis has emerged as a global health challenge, and Australia is no exception to its devastating impact. Opioids are powerful pain-relieving medications, commonly prescribed to manage severe pain. However, over the past few decades, the misuse and overprescription of opioids have given rise to a concerning public health crisis in the country. This article sheds light on the opioid crisis in Australia and emphasises the critical need for doctors to carefully assess patients before prescribing these medications.


The opioid crisis has become a pressing concern, leading to harmful consequences for individuals and communities worldwide. Before exploring the nuances of the opioid crisis let us define what is generally interpreted by the term “opioid crisis”. Opioids represent a class of analgaesic medication that currently is and has been integral to the practice of medicine. Like all pharmaceutical agents, physiological effects may be therapeutic or harmful, desirable, or adverse. The utility of prescribing medication relies on the clinical acumen of the doctor to determine the relative risks and benefits for their patient.


An informed and autonomous patient is equipped to consent or decline any medical intervention pertaining to their health. This fundamental principle applies also to the prescription of opioids to address often debilitating chronic pain symptoms. How has the utility and consumption of opioids turned into a crisis? This is reconcilable by understanding that there is no opioid crisis, but there is a dramatic increase in poorly managed chronic musculoskeletal pain, in particular spine related back pain. Describing the situation as a desperate “opioid crisis” only masks the real crisis of failing musculoskeletal rehabilitation methodologies which drives up the epidemic of chronic pain patients. People suffering chronic pain understandably seek out multifaceted pain management which includes opioid analgesia. They absolutely understand the risks and benefits of opioids and choose to use them to maintain at least some semblance of life quality. To deny this informed choice or insist that the solution be a broad reaching deprescribing campaign, without first attempting to untangle the real crisis is simply cruel.


The real crisis and critical question to ask is, “why is chronic pain, in particular chronic musculo-skeletal pain and low back pain becoming so prevalent in our society”. Who are the industry stakeholders that address musculoskeletal pain and what is their accountability for outcomes? What are industry rehabilitation practices and are they clinically valid. Chronic back pain patients remain on a never-ending merry-go-round in search of the elusive magic treatment. A quick search of the Cochrane Database of common back pain interventions reveals scant validity. If our efforts are directed toward educating clinicians and the public about addressing root causes for musculoskeletal pain with valid rehabilitation interventions, we are guaranteed to reverse what is now being framed as the “opioid crisis”.


Sequential publications of the Australian Burden of Disease studies identify an increasing prevalence of back pain ranking closely behind the top-ranking coronary artery disease. CAD rates are however improving while back pain is worsening. The Quality in Back Pain Care Guidelines are meaningless and indifferent to years gone by. It remains a foregone conclusion that if we keep doing things that do not work for musculoskeletal pain, if we don’t take accountability for our rehabilitation methodologies and outcomes, the crisis will deepen. But the crisis is not the opioids.


What is the cause focused clinical model for the epidemic of back pain symptoms. For a condition to reach epidemic proportions, by definition it must have a ubiquitous cause. Yet for over 90% of patients presenting with chronic low back pain symptoms, the term ‘Non-Specific Low Back Pain’ is assigned. Non-specific implies “we don’t know, there is no cause and we’ve stopped thinking about addressing the cause”. In any field of medicine this is a real crisis. If the back pain therapeutic industry resigns to only addressing the symptoms of pain, we will continue to force people to make the difficult trade-off between the risks and benefits of opioids. Many will accept the adverse effects and still choose opioids over chronic pain. To then advocate and pressure chronic pain patients into a deprescribing of opioid pain medication for the crisis we ourselves created is illogical and unethical.


This is the lived experience currently with an increasing focus on addressing this crisis, there is a strong push from within the medical community for opioid deprescribing as a potential solution. However, while this approach may be a part of the strategy, it should not be viewed as the sole remedy to the complex issue of opioid misuse and chronic pain management.


The Emotional Toll of Chronic Pain


The emotional toll of chronic pain is a deeply concerning aspect that demands urgent attention and empathy from society. Chronic Pain Australia's National Pain Survey 2023 brought to light the devastating impact of chronic pain on individuals' emotional and mental well-being. The survey results were both shocking and disheartening, revealing that a staggering 1 in 2 Australians living with chronic pain experienced thoughts of suicide.


The case study of Jane, a 40-year-old mother of two, illustrates the profound emotional and mental struggles faced by those living with chronic pain. As a result of a workplace injury, for the past five years, Jane has battled excruciating lower back pain, which has made even simple daily activities seem insurmountable challenges. Her pain has led to sleepless nights, isolation from her family and friends, and the loss of her job. Despite seeking medical help and undergoing numerous treatments, Jane's pain remains unrelenting, leaving her feeling helpless and hopeless.


As Jane's pain persists, her emotional state deteriorates. She struggles with feelings of worthlessness, guilt for being unable to fully participate in her children's lives, and the fear of being a burden to her family. The constant pain and emotional distress have led Jane to contemplate taking her own life, feeling that there is no escape from the suffocating grip of chronic pain.


The emotional appeal of Jane's case highlights the critical importance of addressing chronic pain in a compassionate and comprehensive manner. It is crucial for healthcare providers, policymakers, and society as a whole to recognise the profound emotional impact of chronic pain and offer support to those living with this debilitating condition.


Efforts to address chronic pain should not be limited to medical treatments alone. A multidisciplinary approach that includes physical therapy, psychological support, social connections, and access to mental health resources are essential for promoting emotional well-being among chronic pain sufferers.


Humanising the Statistics


Chronic pain is a widespread issue in Australia, affecting millions of individuals and significantly impacting their quality of life. According to a 2022 Pharmacy Guild Report and a 2021 report by Chronic Pain Australia, an organisation dedicated to improving pain management:

  • One in five Australians live with chronic pain, which translates to approximately 5 million people experiencing persistent pain on a daily basis.

  • Chronic pain is the third most costly health condition in Australia, with an estimated cost of $73.2 billion annually, including healthcare expenses, lost productivity, and decreased work participation.

  • Around 68% of chronic pain sufferers reported that their pain interferes with their daily activities, including work, social interactions, and hobbies.

  • Among those living with chronic pain, 52% experience anxiety and 45% suffer from depression, illustrating the strong link between chronic pain and mental health challenges.

  • Approximately 1 in 5 people with chronic pain experience severe to very severe pain levels, impacting their ability to engage in regular activities and leading to increased dependency on pain medication.

Globally, the issue of opioid use and abuse is also a significant concern. According to the World Health Organisation (WHO):

  • The misuse of prescription opioids is a global problem, with an estimated 27 million people worldwide suffering from opioid use disorders in 2021.

  • In the United States alone, approximately 2.1 million people are estimated to be affected by opioid use disorder, with 130 Americans dying each day from opioid-related overdoses.

Australia, like many developed nations, has witnessed an alarming rise in opioid-related deaths and addiction rates. The crisis gained momentum in the late 1990s when pharmaceutical companies aggressively marketed opioids as safe and effective pain relievers, downplaying their addictive nature. Consequently, many patients developed dependency and addiction to these medications, leading to a significant increase in opioid-related fatalities and overdoses.


According to the Australian Institute of Health and Welfare (AIHW), approximately 3,000 people died due to opioid-related overdoses in 2020, marking a disturbing 50% increase over the previous decade. The crisis has profound consequences on families, communities, and the healthcare system, necessitating urgent action to address the root causes.


Dean’s Story


Dean's story is a poignant example of the human toll of chronic pain and opioid use. Dean, a 45-year-old construction worker and family man, suffered a severe back injury on a construction site. The excruciating pain from his injury made it difficult for him to continue working, affecting his ability to provide for his family and maintain his livelihood.


Frustrated by the lack of effective pain management, Dean's doctor prescribed opioids to help alleviate his suffering temporarily. Initially, the medication provided some relief, enabling him to function with less pain. However, as time went on, Dean's tolerance to opioids increased, and he found himself needing higher doses to achieve the same pain relief.


Unaware of the risks associated with long-term opioid use, Dean continued to rely on the medication to manage his chronic pain. As his dependence on opioids grew, he experienced a range of side effects, including drowsiness, mood swings, and cognitive impairment.


Eventually, Dean's opioid use transitioned from medical necessity to addiction, as he found himself unable to cope without the medication. His life spiralled out of control, affecting his relationships with family and friends, and jeopardising his employment.


Dean's experience illustrates the urgent need for comprehensive pain management strategies that address the underlying causes of chronic pain while minimising the reliance on opioids. Humanising the statistics with individual stories like Dean's highlights the devastating impact that chronic pain and opioid misuse can have on people's lives, making it imperative for healthcare professionals, policymakers, and society as a whole to prioritise compassionate and effective pain management approaches. By sharing these narratives, we aim to advocate for better support systems and resources for those suffering from chronic pain, fostering empathy and understanding for their struggles and journey towards recovery.


The Role of Health Professionals


Health professionals, as frontline caregivers, bear a significant responsibility in addressing the opioid crisis and promoting responsible pain management. Their actions and decisions can have a profound impact on patients' lives, making it crucial for them to stay informed about the potential risks associated with opioid use and seek alternatives for managing chronic pain.


Most importantly is that clinicians and patients distinguish between symptom-based care and cause based care for pain. Nowhere is this more critical than in musculoskeletal pain and back pain. The massive majority of low back pain is biomechanical in origin and hence an essential component of treatment must have a biomechanical movement proficiency focus. The take home message for patients and clinicians is to realise that the most significant factor that contributes to the health of the musculoskeletal system and joints is STABILITY. Any therapeutic intervention designed to address the root cause of joint related nociception and inflammation must fundamentally improve joint stability. Purely symptom-based management methods that do not enhance the biomechanics and stability of any joint or the inherently unstable lumbar spinal motion segments will ultimately fail.


Pain medications, injection procedures, manual therapy and massage, core strengthening and stretching in isolation are not in and of themselves harmful and may provide temporising pain symptom relief, but they do not enhance coordinated skilful movement proficiency which is a critical component of joint stability. If the lumbo-pelvic biomechanics of movement proficiency and stability are not restored through specific and distinctive Functional Movement Therapy the spinal joints will, without doubt remain or relapse into pain.


Regarding chronic back pain management guidelines physical therapy associations and professional colleges need to review and validate intervention methodology. Numerous first line back pain interventions that every back pain sufferer will have repeated countlessly have very little scientific validation. Although in isolation repeating these poorly effective interventions may not directly cause harm, they may be detrimental to the patient who is financially limited and potentially steer the patient away from more effective remedies. With the passage of time a failure to reverse the cause of pain effectively, transforms pain pathophysiology into a state of central functional pain which is even more challenging to manage than primary periphery structural pain. Those in the back pain service industry need to be accountable for the outcomes of their service delivery.


In practice, health professionals can play a pivotal role in several key areas:

  • Patient Education: Health professionals have a unique opportunity to educate patients about the risks and benefits of opioid medications. By providing comprehensive information about pain management options, including non-opioid treatments, patients can make informed decisions about their health.

  • Prescribing Practices: Health professionals can exercise caution when prescribing opioids, especially for chronic pain. They should carefully assess each patient's medical history, pain severity, and risk factors for potential opioid misuse or addiction. When opioids are deemed necessary, prescribing the lowest effective dose for the shortest duration possible can help minimise the risk of dependency.

  • Incorporating Non-Opioid Treatments: Emphasising the use of non-opioid treatments, such as physical therapy, cognitive-behavioural therapy, acupuncture, and other outcomes-based therapies, can be an effective way to manage chronic pain without relying solely on opioids.

  • Integrative Pain Management: Encouraging a multidisciplinary approach to pain management can enhance patient outcomes. By collaborating with other healthcare professionals, such as pain specialists, psychologists, and physical therapists, health professionals can provide more comprehensive and tailored treatment plans for their patients.

  • Regular Assessment and Monitoring: Health professionals should regularly assess their patients' pain levels, treatment effectiveness, and potential adverse effects. Close monitoring enables them to adjust treatment plans as needed and identify any signs of opioid misuse or dependence promptly.

Case Study


Dr. Sarah Miller, a family GP, recognised the importance of her role in addressing the opioid crisis after attending a continuing medical education seminar on responsible pain management. Determined to make a positive impact, Dr. Miller implemented several changes in her practice.


First, she began dedicating more time during patient consultations to discuss pain management options thoroughly. She provided brochures and educational materials that explained the potential risks of opioid use and the alternative treatments available.


When evaluating patients with chronic pain, Dr. Miller prioritised non-opioid treatment options, such as physical therapy, and exercise regimens that focused more on Movement Proficiency and skill acquisition than those that are passive and non-functional in nature, and mindfulness-based stress reduction techniques. For patients who required pain medication, she prescribed opioids judiciously, taking into account their medical history and potential risk factors for addiction.


To complement her approach, Dr. Miller collaborated with a local neurosurgeon who specialises in spinal care, plus pain specialists and physical therapists to create comprehensive treatment plans for her patients. She also attended interdisciplinary case conferences to gain valuable insights from other healthcare professionals, enhancing her ability to provide patient-centred care. She attended online Masterclasses with Australian Medical Network and discovered firsthand how to critically think and best support her patients.


Through regular follow-ups, Dr. Miller monitored her patients’ progress closely, adjusting their treatment plans based on their response to interventions. As a result of her proactive approach, several patients were able to reduce their reliance on opioids and experience significant improvements in their pain management.


Dr. Miller’s commitment to responsible pain management has not only improved patient outcomes but also contributed to reducing opioid dependency in her community. Her example serves as a testament to the vital role that health professionals play in tackling the opioid crisis and promoting compassionate and effective pain management practices.


Ultimately inadequate pain management and a lack of understanding of opioids' potential risks and benefits contribute to the opioid crisis. A significant factor in this crisis is the inaccurate prescription of opioids without comprehensive patient assessment. Prescribers, including doctors and healthcare professionals, play a pivotal role in mitigating the opioid epidemic. They must carefully evaluate a patient's medical history, pain condition, and risk factors before deciding on opioid therapy.


A careful assessment involves considering alternative pain management approaches, assessing a patient's potential for addiction, and identifying any coexisting mental health conditions that may exacerbate the risk of opioid misuse. By adopting evidence-based guidelines and clinical assessments, prescribers can ensure that opioid medications are only used when necessary and when other less addictive treatment options have proven ineffective.


Regulatory Measures and Prescription Monitoring Programs


In response to the opioid crisis, Australian authorities have taken regulatory measures to control the prescription and distribution of opioids. Prescription monitoring programs have been implemented in several states to track opioid prescriptions and identify potential instances of misuse and overprescription. These programs help identify high-risk patients, prevent doctor-shopping, and provide early intervention to those showing signs of opioid dependence.


Holistic Approach to Pain Management


By treating the root cause of the pain, health professionals can break the cycle of opioid reliance and improve the overall quality of life for patients. This approach integrates various modalities, each addressing different aspects of pain, physical and emotional well-being, and empowering patients to take charge of their health.


Meet Sarah, a 35-year-old woman who has been experiencing chronic low back pain for several years. She initially sought relief from her discomfort through prescribed opioids, but over time, she found herself increasingly reliant on these medications to function. However, the pain persisted, and she began to realise that masking the symptoms with opioids was not the long-term solution she had hoped for.


At this point, Sarah’s primary care physician, Dr. Johnson, recommended a holistic approach to pain management. Dr. Johnson believed that addressing the underlying causes of Sarah’s pain could provide her with lasting relief and reduce her reliance on opioids. Together, they formulated a comprehensive pain management plan that embraced multiple modalities.


First, Dr. Johnson referred Sarah to a physical therapist who specialised in musculoskeletal issues. The therapist assessed her posture, muscle imbalances, and movement patterns to identify any mechanical factors contributing to her low back pain. Through targeted exercises, stretches, and postural corrections, Sarah began to notice improvements in her pain levels and functional abilities.


Recognising that chronic pain often has an emotional component, Dr. Johnson referred Sarah to a psychologist experienced in pain management. Through counselling sessions, Sarah learned coping strategies for dealing with pain-related stress, anxiety, and depression. Addressing these emotional aspects not only helped Sarah better manage her pain but also improved her overall mental well-being.


Additionally, Sarah explored alternative therapies, such as acupuncture and mindfulness meditation, as part of her pain management plan. Acupuncture sessions provided relief from muscle tension, while mindfulness meditation techniques helped her develop a more positive outlook on her pain and its impact on her life.


Over time, Sarah’s dependence on opioids reduced significantly. The holistic approach empowered her to manage her pain effectively by addressing the underlying physical and emotional factors contributing to her discomfort. As a result, Sarah regained a sense of control over her health, allowing her to live a more fulfilling and active life without the burden of chronic opioid use.


By combining multi-disciplines such as physical, psychological, and alternative therapies, healthcare providers can transform the lives of patients like Sarah, providing them with lasting relief and a brighter outlook on their future. Embracing this comprehensive approach not only reduces opioid reliance but also fosters a more patient-centred and compassionate approach to pain management.


Treating pain and addressing the opioid crisis requires a multidisciplinary approach involving healthcare providers, policymakers, public health officials, medical and community organisations. By fostering collaboration and communication, it becomes possible to develop comprehensive strategies that integrate various pain management modalities, psychological interventions, and social support networks.

Non-pharmacological treatments, such as physical therapy, cognitive-behavioural therapy, and acupuncture, should be promoted alongside pharmacological options to minimise the reliance on opioids for pain relief. Education and training programs should also be implemented for healthcare professionals to improve their understanding of pain management and the appropriate use of opioids.


Conclusion


The opioid crisis is undeniably a significant and complex issue that has had far-reaching consequences on individuals and communities, not only in Australia but worldwide. While the term "opioid crisis" has become prevalent in discussions surrounding this matter, it is crucial to recognise that the crisis itself is multifaceted and extends beyond the realm of opioids alone.


The heart of the crisis lies in the escalating prevalence of chronic musculoskeletal pain, particularly chronic back pain. Rather than solely attributing the crisis to opioids, it is imperative to delve deeper into the root causes of this widespread pain epidemic. Assigning a diagnosis of "Non-Specific Low Back Pain" to the majority of patients with chronic back pain reflects a troubling trend of overlooking the underlying causes of this condition. This approach not only fails patients but also perpetuates a cycle of symptom-focused care that may inadvertently contribute to the reliance on opioid medications.


The solution to the opioid crisis requires a comprehensive and cause-focused clinical model that addresses the true origins of chronic pain. This approach entails a thorough examination of industry rehabilitation practices, accountability for patient outcomes, and a shift toward valid and effective rehabilitation interventions. By identifying and addressing the root causes of musculoskeletal pain, we can potentially reverse the escalating crisis and mitigate the need for excessive opioid use.


While opioid deprescribing may play a role in the broader strategy, it cannot stand alone as the ultimate solution. Instead, a holistic approach that encompasses education, valid rehabilitation practices, and a re-evaluation of how chronic pain is diagnosed and managed is essential. By reframing the crisis as a call to action for comprehensive and cause-focused care, we can work collectively to alleviate the burden of chronic pain and create a healthier and more effective approach to pain management for individuals and society as a whole.

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