The Opioid Epidemic.

In the United States, over 100 million people suffer from chronic pain or around one-third of adults. (1) In 2012, over 259 million opioid prescriptions were written. (2) Four out of five heroin users admit to abusing their own painkiller prescriptions prior to trying heroin.3

Opioids refer to a class of drugs with effects similar to opium, such as oxycodone (OxyContin) and hydrocodone (Vicodin). They are most often used in the treatment of pain and have side effects including sedation, respiratory depression, gastrointestinal upset, and euphoria. Long-term users develop a tolerance to the drug and may experience rebound effects upon withdrawal, such as hyperalgesia, tremors, irritability, diarrhea, and dysphoria.

The Consequences of Over-Prescribing

Although the use of opiates actually predates recorded history, only now are the consequences of over-prescribing being realized. Over the past twenty years in the U.S., prescription painkiller sales have quadrupled, as have overdose-related deaths. The admission rate for opioid addiction treatment centers has gone up six-fold. (4)
Aggravating the issue is the current model of drug addiction in the United States, the country with the (highest rate of incarceration in the world. It’s estimated that two-thirds of those incarcerated have substance use disorders and that one in four has opioid use disorder. (5,6) Almost 75% of these individuals will relapse to opioids within three months of release from prison. (7)
In addition, our research on opioids is lacking. There are virtually no studies that compare long-term opioid use with alternative methods to treat pain. There are also very few studies that examine the harms of long-term use, but the data suggest a dose-dependent increased risk of fractures, abuse, and overdose. (8)

Options for Long-Term Pain

The opioid epidemic is a result of an unsustainable solution to a widespread problem, a solution which statistically leads to tolerance, dependence, and placement into a legal system which views the issue as criminal rather than medical. We assign the most convenient treatment option while ignoring its inconvenient consequences on society. Legal reform is slow to take place, but the concern at-hand is finding effective treatment options for chronic pain.
Research has shown that different forms of physical therapy can have a positive impact on long-term pain. (9) A literature review compiling alternative treatment studies found that these options could work better than placebo and pain medication, offering an effective and safe method of pain relief. (11) Educating patients about how pain is generated by the brain is a critical intervention in preventing and overcoming chronic pain. This is best achieved by a physical therapist educated in pain science who can combine education with movement. Cognitive behavioral strategies are also needed to help patients reframe pain, work on issues such as acceptance, forgiveness and their relationship with pain. 
Exercise is another option, which has been shown to significantly reduce pain across studies in programs as short as three weeks.(12) High-intensity workouts were actually found to be most effective, with the only drawback being initial muscle soreness.
Studies have also found correlations between chronic pain and depression; depression can lead to chronic pain, and vice versa. (13) As nutrition and exercise have been shown to have positive effects on symptoms of depression, individuals may find relief in using these methods to further alleviate chronic pain.
Millions of Americans suffer from chronic pain, and our reaction has been the simplest: to prescribe bottles of medication with no plan for long-term relief. The consequences are visible, and those who are suffering deserve not only several treatment options but options that keep their mental health in mind.
Appropriate timing and dosage of opioids may be warranted in certain types of conditions.
However, embracing a biopsychosocial model of care is needed to cure our epidemic opioid addiction & chronic pain.
In health,
Dr. Joe Tatta, DPT, CCN
References

1. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. REPORT BRIEF JUNE 2011; Johannes et al. The prevalence of chronic pain in United States adults: results of an Internet-based survey. J Pain. 11(11):1230-9. (2010); Gallup-Healthways Well-Being Index.
2. Centers for Disease Control and Prevention. (2014). Opioid Painkiller Prescribing, Where You Live Makes a Difference. Atlanta, GA: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vitalsigns/opioid-prescribing/

3. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.
4. Paulozzi MD, Jones PharmD, Mack PhD, Rudd MSPH. Vital Signs: Overdoses of Prescription Opioid Pain Relievers –United States, 1999-2008. Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Center for Disease Control and Prevention. 2011:60:5.
5. Mumola CJ, Karberg JC. Drug use and dependence, state and federal prisoners, 2004 (revised 1/19/07) Washington, DC: U.S. Department of Justice; 2006.
6. Karberg JC, James DJ. Substance dependence, abuse, and treatment of jail inmates, 2002. Washington DC: U.S. Department of Justice; 2005.
7. Fox, A. D., Maradiaga, J., Weiss, L., Sanchez, J., Starrels, J. L., & Cunningham, C. O. (2015). Release from incarceration, relapse to opioid use and the potential for buprenorphine maintenance treatment: a qualitative study of the perceptions of former inmates with opioid use disorder. Addiction Science & Clinical Practice, 10(1), 2. http://doi.org/10.1186/s13722-014-0023-0
8. The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.
9. Hsieh CY, Phillips RB, Adams AH, Pope MH.  Functional outcomes of low back pain: comparison of four treatment groups in a randomized controlled trial. J Manipulative Physiol Ther. 1992; 15:4-9.
10. Chou R, Huffman LH. Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2007;147:492-504. doi:10.7326/0003-4819-147-7-200710020-00007
11. James Rainville, Carol Hartigan, Eugenio Martinez, Janet Limke, Cristin Jouve, Mark Finno, Exercise as a treatment for chronic low back pain, The Spine Journal, Volume 4, Issue 1, 2 January 2004, Pages 106-115, ISSN 1529-9430, http://dx.doi.org/10.1016/S1529-9430(03)00174-8.
12. G. Magni, C. Moreschi, S. Rigatti-Luchini, H. Merskey, Prospective study on the relationship between depressive symptoms and chronic musculoskeletal pain, Pain, Volume 56, Issue 3, March 1994, Pages 289-297, ISSN 0304-3959, http://dx.doi.org/10.1016/0304-3959(94)90167-8.