Fall 2023 - Vol. 18, No. 3 The article by Dr. Jon Lepley in this issue highlights that restrictions regarding chronic therapy for opioid use disorder have been lifted and suggests ways to unlock barriers to treatment. We are excited to have Dr. Lepley offer this narrative to JLGH readers. Further, we welcome all providers who have not yet received their X-waiver to join those who work in Addiction Medicine and all colleagues already in the thick of the fight in the opioid epidemic.

Undoubtedly, chronic pain and the use of opioids to treat it have contributed to this problem. Pain that lasts beyond the time of normal tissue healing, or longer than three months, puts our patients at risk for chronic pain medication use.¹ At least 20% of the U.S. population — representing 50 million adults — report suffering from chronic pain; the numbers are likely higher.^2,3

But there are viable alternatives. The first recommendation within the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain reminds us to initially consider non-opioid therapies, as they are at least as effective as opioids for acute pain. Further, it states that clinicians should maximize use of non-pharmacologic therapies, such as heat therapy, acupressure, spinal manipulation, remote electrical neuromodulation, massage, and exercise therapy.⁴

Other guidelines make similar suggestions — that manipulative therapies, heat, exercise, and acupuncture should be considered early, if not first, in the management of chronic pain.^5-7 Many of our patients may benefit from and can even pursue non-pharmacologic and adjunctive therapies independently. Self-referrals to physical therapy, as well as spinal manipulation and acupuncture, can be appropriate, although reimbursements for specific therapies often need the secondary approval of a physician or are not covered at all. This is a snag that policymakers would do well to reconsider so that our clinical colleagues can practice at the highest level of their licenses.

September is Pain Awareness Month, and in October we celebrate Physical Therapy Month and Acupuncture Awareness, so it seems a good time to thank our colleagues in these practices and think about how we can safely help our patients negotiate pain syndromes.

Throughout Penn Medicine Lancaster General Health, we have 16 outpatient physical therapy (PT) centers available to work with us and for our community. While fast-track back-pain referrals have made access easier, many of our patients still don’t feel they have the time, the copay, or the energy to engage in the therapy they need. Thus, efforts are warranted to decrease barriers and increase research to improve access and integrate the use of social determinants of health into the assessment and treatment design in these practices.

For example, wait times in Lancaster for an initial outpatient PT assessment can approach two weeks, so more physical therapists need to be hired. Further, while efforts to change the delivery model for PT during the SARS-CoV-2 pandemic led to telehealth PT — which was well received locally and nationally⁸ — there is a looming deadline to pandemic-era approval of such modalities. Unless the Expanded Telehealth Access Act (H.R. 3875) is approved, this meaningful option will go away in December 2024.

More efforts to innovate and eliminate barriers are in order. Once our colleagues in the Physical Medicine and Rehabilitation department are appropriately staffed, they would do well to connect with those in LG Health’s Research Institute and the Center for Health Care Innovation to work on innovative care models to increase access and effectiveness of care.

Robust data demonstrate that acupuncture and massage can have significant impact on the lives of patients either alone or when combined with other modalities.^9-10 Data support acupuncture use in chronic pain and a variety of syndromes, including as treatment for migraine, fibromyalgia, and chronic back pain.^11-13

LG Health’s Holistic Therapy program employs four traditionally trained acupuncturists, along with nearly 35 massage therapists; wait times for each are very minimal. Legislation is still not adequate to allow these health care professionals to care for everyone, however. Changes to allow government-funded insurance recipients the option to have acupuncture and massage therapy for acute and chronic pain could decrease inappropriate and dangerous pharmacologic prescribing.

As cooler weather approaches and the leaves change, let’s think about ways we can better approach the treatment of chronic pain and opioid use disorder, and expeditiously connect our patients with the safest modalities available. We hope you enjoy this issue of JLGH.

REFERENCES
1. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl. 1986;3:S1-S226.
2. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults — United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67:1001-1006.
3. Yong RJ, Mullins P, Bhattacharyya N. Prevalence of chronic pain among adults in the United States. Pain. 2022;163(2):e328-e332.
4. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016 [published correction appears in MMWR Recomm Rep. 2016;65(11):295]. MMWR Recomm Rep. 2016;65(1):1-49.
5. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.
6. Nielsen A, Dusek JA, Taylor-Swanson L, Tick H. Acupuncture therapy as an evidence-based nonpharmacologic strategy for comprehensive acute pain care: the Academic Consortium Pain Task Force white paper update. Pain Med. 2022;23(9):1582-1612.
7. Task Force on the Low Back Pain Clinical Practice Guidelines. American Osteopathic Association guidelines for osteopathic manipulative treatment (OMT) for patients with low back pain. J Am Osteopath Assoc. 2016;116(8):536-549.
8. Miller MJ, Pak SS, Keller DR, Barnes DE. Evaluation of pragmatic telehealth physical therapy implementation during the COVID-19 pandemic. Phys Ther. 2021;101(1):pzaa193.
9. Liu M, Tong Y, Chai L, et al. Effects of auricular point acupressure on pain relief: a systematic review. Pain Manag Nurs. 2021;22(3):268-280.
10. Crawford C, Boyd C, Paat CF, et al. The impact of massage therapy on function in pain populations — a systematic review and meta-analysis of randomized controlled trials: part I, patients experiencing pain in the general population. Pain Med. 2016;17(7):1353-1375.
11. Li YX, Xiao XL, Zhong DL, et al. Effectiveness and safety of acupuncture for migraine: an overview of systematic reviews. Pain Res Manag. 2020;2020:3825617.
12. Han D, Lu Y, Huang R, et al. Acupuncture for fibromyalgia: a review based on multidimensional evidence. Am J Chin Med. 2023;51(2):249.277.
13. Mu J, Furlan AD, Lam WY, Hsu MY, Ning Z, Lao L. Acupuncture for chronic nonspecific low back pain. Cochrane Database Syst Rev. 2020;12(12):CD013814.