Chasing the Dragon: Driving the Paradigm Shift to Move Beyond Opioids.

SYNOPSIS: The opioid crisis is more severe in the United States than in any other country. This may be due, in part, to a cultural problem related to pain: Americans have come to expect quick, easy, physician-provided pain relief. Pharmaceuticals can neither cure injuries nor correct the underlying cause of any chronic musculoskeletal condition. Fortunately, people who regularly exercise have less pain, and guidelines for the management of painful chronic conditions already recommend exercise therapies over passive care. This suggests that self-care approaches emphasizing exercise are the logical, lowest-cost, first-line treatment. For patients who require guidance with exercise, the stepped-care approach to pain management commonly taught in medical school curricula should include guided physical rehabilitation early, if not first. This has been shown to be associated with fewer high-cost services and less opioid medication. Keeping people opioid naïve, when appropriate, could save tens of thousands of American lives annually and many more globally. Attitudes, behaviors, and policies must evolve to shed the culture of first-line pharmaceutical pain management. J Orthop Sports Phys Ther 2020;50(12):661-663. doi:10.2519/jospt.2020.0611.

Chasing the Dragon: Driving the Paradigm Shift to Move Beyond Opioids.

SYNOPSIS: "Chasing the dragon" is a term that originated 150 years ago in China after the Opium Wars to refer to the act of heating opium and inhaling its vapor. The phrase has a second meaning, describing the dangerous pursuit of the mythical, ultimate high. However, health systems are using opioids in the pursuit of something likely mythical but similarly elusive - a passive treatment for pain that is rapid, effective, and safe. Regrettably, this worldwide pursuit is treacherous on an immense scale. The opioid crisis is more severe in the US than in any other country. This may be due, in part, to a cultural problem related to pain: Americans have come to expect quick, easy, physician-provided pain relief. We must admit that pharmaceuticals can neither cure injuries nor correct the underlying cause of any chronic musculoskeletal condition. Fortunately, people who regularly exercise have less pain, and guidelines for the management of painful chronic conditions already recommend exercise therapies over passive care. This suggests that self-care approaches emphasizing exercise are the logical, lowest-cost, first-line approach. For patients requiring guidance with exercise, the stepped care approach to pain management commonly taught in medical school curricula should include guided physical rehabilitation early, if not first. This has been shown to be associated with fewer high-cost services and less opioid medication. Keeping people opioid-naïve, when appropriate, might save tens of thousands of American lives annually and many more globally. Attitudes, behaviors, and policies must evolve to shed the culture of first-line pharmaceutical pain management. J Orthop Sports Phys Ther, Epub 19 Oct 2020. doi:10.2519/jospt.2020.10210.

Examining Drivers of Health Care Spending: Evidence on Self-referral Among a Privately Insured Population.

BACKGROUND: Despite the enactment of laws to restrict the practice of self-referral, exceptions in these prohibitions have enabled these arrangements to persist and proliferate. Most research documenting the effects of self-referral arrangements analyzed claims records from Medicare beneficiaries. Empirical evidence documenting the effects of self-referral on use of services and spending incurred by persons with private insurance is sparse. OBJECTIVES: We analyzed health insurance claims records from a large private insurer in Texas to evaluate the effects of physician self-referral arrangements involving physical therapy on the treatment of patients with frozen shoulder syndrome, elbow tendinopathy or tendinitis, and patellofemoral pain syndrome. STUDY DESIGN: We used regression analysis to evaluate the effects of episode self-referral status on: (1) initiation of physical therapy; (2) physical therapy visits and services for those who had at least 1 visit; and (3) total condition-related insurer allowed amounts per episode. RESULTS: For all 3 conditions, we found that patients treated by physician owners were much more likely to be referred for a course of physical therapy when compared with patients seen by physician nonowners. A consistent pattern emerged among patients who had at least 1 physical therapy visit; non-self-referred episodes included more physical therapy visits, and more physical therapy services per episode in comparison with episodes classified as self-referral. Most self-referred episodes were short and the initial visit did not include an evaluation. CONCLUSION: Physician owners of physical therapy services refer significantly higher percentages of patients to physical therapy and many are equivocal cases.