Beyond Opioids: Transforming Pain Management to Improve Health


From APTA headquarters in Alexandria,
Virginia this is “Beyond Opioids:Transforming Pain
Management to Improve Health.” I’m Jason Bellamy, and tonight you’re
going to get seven different perspectives on the opioid epidemic over three
different panels. Will also be debuting APTA’s #ChoosePT public service
announcement. Before we go any further though let’s talk about why we’re here,
and what we hope to explore tonight. The opioid epidemic is an ongoing and
serious problem. Survey estimates indicate that 2.4 million Americans have an opioid use disorder. Prescription opioid misuse is thought to increase health care and substance abuse treatment costs in this country by 29
billion dollars. In 2016, American life expectancy at birth declined for the second straight year, the first time that’s happened since the early 1960s. This is an urgent problem. It’s an urgent issue. But so is pain. Pain is often the reason the people enter the healthcare system. We must not minimize what it
means to live with pain. Pain can be overwhelming; it’s no wonder that doctors
looking out for their patients’ best interests have looked to mask that pain
by prescribing opioids opioids in recent years with increased frequency. We must also not forget that, properly dosed, opioids an appropriate part of health care treatment particularly for cancer treatment and
end-of-life care. But we also must not ignore the larger trend. Despite an increase in opioid prescriptions, the amount of Americans reporting pain has not decreased, but Americans’ overall health has decreased. Tonight’s event is built on a basic premise: there are multiple ways to treat, manage, and prevent pain. And we must increase awareness of, and access to, non-opioid options. Before I introduce our first panel of three tonight, I’d like to introduce APTA President Sharon Dunn to offer a few remarks. Sharon? Thank you, Jason. First, I want to welcome everyone. Thank you for those of you who came from close to be with us today in our studio
audience right here at APTA headquarters in the Mary McMillan
conference room. I also want to thank those of you who have joined us on
Facebook live those PT’s PC assistants and students who have already put in a
full Monday appreciate you joining us tonight
also joining us may be people who this epidemic cuts very close to home I want
to thank you for looking to us for hope and a new message to manage your pain I
also want to thank our panelists who have come from across the country to
join us tonight and giving your time and energy to helping us work together to
deal with this terrible tragedy of opioid addiction in this country and to
those of you who are who are watching live as you sit there in your homes and
in your communities I want you to think about how as you listen to these
panelists discuss the epidemic and what we can do together I want you to think
about how you can join this to create a societal solution that we all need to
join because if we’re going to transform society it’s going to take all of us not
only in our profession but an interdisciplinary approach to to make a
difference so think of how you can make that difference right there in your
hometown and your communities thank you all for joining us appreciate this and I
look forward to hearing the discussion thank you sharing done so now introduce
our first panel and I’m going to start at the far right of your screen with
Congressman Donald Norcross he represents the first District of New
Jersey he’s also the vice chair the bipartisan task force to combat the
heroin epidemic just to his right is grant Baldwin the director of the
division of unintentional injury prevention for the Centers for Disease
Control and Prevention and then immediately to my left is Joan Maxwell
and Joan I’m going to start with you tonight you’re a patient and family
advisor for Jon your health you’re a member of the patient and
family-centered care partners more importantly you are a real
life example of someone who’s been impacted by the opioid epidemic you had
multiple interactions with the healthcare system at a time before we
were really talking about alternatives to opioids before we were talking about
the risks of opioids speaking about your personal experience first take me
through that what was your experience with the
healthcare system at the time okay well first of all I want to just say thank
you for including the voice of a patient here today that’s really important that
we all work together I was diagnosed with breast cancer in 2014 and had a
double mastectomy and a few weeks after what I thought was the flu and just went
to bed for three days turned out to be a raging staph infection so I ended up
back in the hospital and had nine surgeries over the course of about two
and a half years after one of those surgeries I had a stroke so I spent two
and a half years in the healthcare system and had a very good experience
overall and I’m healthy today but I learned thank you thank all of you but I
learned a lot from that experience nine times I had surgery and nine times I was
prescribed opioids and nine times I never had a discussion with a doctor in
advance about what my pain experience might be and what my options might be so
one of the things that I really feel strongly about is there’s just a
wonderful opportunity for communication and for patients to be educated in
advance about pain and about their choices and not just given a
prescription for opioids I managed my opioids pretty well I was very conscious
of it and determined to be extremely cautious
but opioids don’t help you recover they don’t help you get your range of motion
back they don’t help you make the progress that you need to make to get
your strength back and return to your life so I had you know like I said a
good experience overall but still lots of room for improvement and
communication and one thing I really want to emphasize is that you know I
consider myself like a somewhat competent person in my regular life but
when this happened to me it was so shocking and surprising and so
incredibly confusing you know sometimes I had a sir I had a breast cancer
surgeon at a reconstruction surgeon I had infectious disease specialist
I had a cardiologist I had a neurologist and I didn’t know who to ask my
questions to I didn’t know how things were gonna happen or what to expect I
didn’t understand the system you know I’m in the fashion business and if you
asked me about that I could talk for hours but I was so naive in this world
and also worried about my job and my kids and all the other things that I you
know maybe I could have done a better job but I needed a lot of help with all
that confusion and then I’ll also say that you get it sent home so early you
know you have I had drains and these pain pumps and all kinds of
paraphernalia to manage and you need a lot of help with that and so that’s
another opportunity so that’s a lot sorry
well nine operations is a lot so you said you you emerge from all this
relatively unscathed right at least as in regards to Tokyo and cancer-free
which is tremendous you had a brother-in-law however who had a
different experience of the opioids and if you don’t mind please share that with
us yes I have a brother-in-law who is addicted to opioids and he had he’s had
two kind of failed back surgeries and this started about six years ago and
unfortunately he had a lot of pain after the surgery and he became addicted to
opioids and to this day it’s a real struggle for our family he is my
sister-in-law has to he’s still in a lot of pain they’re actually considering a
third surgery but he she has to manage his pills and hide them and give them to
him daily he has a fentanyl patch and opioids in a way are keeping him going
and they’re also ruining his life and his family’s life and he’s had to detox
several times he had to do it at home with his kids and his wife helping him
which I’m sure everyone can imagine how devastatingly painful that is to have
your kids see you go through that he can’t sit at the dinner table with his
family and eat dinner he’s he’s a mess and and he’s a wonderful person and if
you he could sit up here with all of us but it’s been devastating for our whole
family and it’s such a good example of what is happening because you know he
was just a regular person like all of us and just one surgery and he was addicted
so I’m here because of him Joanie but you
mentioned the the need for conversations and the need for greater awareness as
people navigate through the healthcare system as your family has grappled with
this what you’ve gone through but then of course what your brother-in-law is
going through right now have you looked at this and seen two starkly different
experiences in terms of how it started or or do you look at this and say you
seem to emerge unscathed and he didn’t and you don’t know why I think it’s a
little serendipitous I really do I think that some people like Larry have kind of
this instant reaction to opioids and it was so much harder for him than it was
for me so that’s one thing and the list of many things that I wonder about in
terms of making a difference is is there a way in the future that we can identify
people who are at risk in a more significant way than others
but also it feels like such a huge opportunity to just have the
conversations in advance and I’m wondering I’m guessing insurance
companies don’t pay for that now but is that something that could be looked at
because to have that conversation I mean my conversation was when I was in my
gown pre up five minutes before being wheeled into surgery pain specialist
came in and made a recommendation that I had no idea what it meant and I’ll just
tell you if you’re about to go into a seven-hour surgery and they offer you
something you say yes I mean there’s no other choice so you know those
conversations if they could be more thoughtful and you could have time to
think about it and also if you were told a little bit more about what level of
pain to expect because I do think that there is going to be some pain and right
now all of these opioids kind of dull that
and make you pain-free which isn’t necessarily the best thing long-term for
your recovery but I don’t think a lot of patients really understand that and it
took me going through this process to kind of absorb and understand that so
that feels like a big opportunity you mentioned several ways that the
healthcare system should should adapt in light of the epidemic in light of your
experience but having been through what you have gone through having been
through what your brother-in-law is going through now what would your advice
be to patients about their responsibilities and their their ability
with it and given the the realities of opioids about how they should enter into
into their health care knowing all the facts that we know now what should they
do I think they need to educate themselves if you know obviously things
happen and not every surgery is planned but if you have the opportunity which
both Larry and I did to know in advance to educate yourself and have a
conversation with your doctor about pain and what is the plan for pain management
and also what is it going to look like to you to be healed I think you know
surgeons heal you and two days later they’re like okay great I did a great
job it looks beautiful bye meanwhile you can’t drive you can’t lift
your luggage to get on a plane and make a trip you can’t cook I mean you have
all this recovery yet ahead of you and so I think there’s a big opportunity for
more discussion around the whole continuum and also for patients to
understand that it might be to their benefit not to take opioids but to use
other forms of pain management I mean I had such a positive experience with
physical therapy as a result of my stroke and I had this you know amazing
physical therapist who came up with new ideas every week
and I got a hundred percent of my strength back on my right side thanks to
her and that wouldn’t have happened with opioids so that’s a great segue to
Graham Baldwin of the CDC grant we’re about two years removed from the CDC
really releasing guidelines on the prescription of opioids related to
chronic pain those guidelines obviously take into account stories like Joan’s
stories like so many Americans who’ve been impacted by this crisis started in
a very high-level first two years post those guidelines they’ve obviously
increased awareness they’ve helped spur the conversation what’s changed pawsley
or negatively how different are we now than we were in March 2016 when those
guidelines were released sure thanks for the question I think a couple of things
have changed first the epidemic has continued to rage as people know we’ve
now lost over 200,000 Americans to opioids since 1999 and while
prescription opioid related deaths plateaued from around 2011 to 2015 they
have gone up again in 2016 and there was a 20% increase in opioid related deaths
the prescription opioid problem has now been sort of confounded and complicated
by the ever-growing illicit problem with heroin and fentanyl and as you mentioned
we released the opioid prescribing guidelines in March of 2016 and much has
changed we knew when we released the guideline that was really just the
starting point that we really had to place a tremendous amount of energy and
translation and dissemination and so we did a few things first on the
translation and communication side we released a whole host of fact sheets and
other materials we have we work with Atul Gawande x’ group on a clinical
algorithm or checklist that clinicians could use we implemented a mobile app
that you can download we are also educating clinicians both
initially and in through continuing medical education we I think the
signature in that space is a 10 part series including one of the modules
that’s out already on treating pain without opioids which we’re really
excited about and we’ve been partnering with schools across the country to
increase guideline concordant care medical schools nursing schools pharmacy
schools and hopefully soon schools of physical therapy we’re also
very encouraged and interested in as you can appreciate what are the non opioid
non pharmacologic and treatment options so we recently funded I’m sure many of
you are familiar with the AHRQ systematic review that was done on what
is the evidence base around non-opioid therapies that’s just out now and I
think there’s growing interest in energy on making sure that those evidence-based
options are covered they’re covered with with the quantity and the duration and
at a level where co-pays are so that people can actually afford these sort of
exercise multimodal rehabilitation frankly your story personified and then
lastly we really see there’s a real power in story and so we’re trying to
raise general public awareness around prescription opioids and the risks of
prescription opioids last September we launched a large-scale communication
campaign with family members who’ve lost loved ones as well as people who are
recovering from their addiction with the tagline it only takes a little to lose a
lot prescription opioids can be addictive and dangerous with that
campaign has gotten wide scale pickup which we’re really excited about and
we’re working with our state-based partners to customize and tailor that so
that ensure it’s what’s changed so as you mentioned the CDC is engaged in a
lot of efforts to increase the evidence-based materials that are out
there but I want to go back to those guidelines because it’s a multi-page
document right it’s it’s a deep and vast guideline there’s a lot of information
there for somebody who’s just heard only aware that there are guidelines that
exist but have not pored through all all of it can you summarize briefly
basically the gist of what those guidelines recommend sure the guidelines
apply for chronic pain for primary care clinicians treating adults in chronic
pain that’s pain lasting longer than three months and there are sort of 12
specific guidelines that cut across three basic principles first that opioid
should not be the first-line choice for treatment of chronic pain if opioids are
you second that they should be done judiciously and cautiously three days is
usual enough caution should be given after
opioids are prescribed at more than 50 morphine milligram equivalents which is
a metric for comparing opioids across one another as Joan mentioned there
should be treatment goals established for opioid therapy and then finally
patients should be monitored carefully over time using things like prescription
drug monitoring programs and urine drug tests and people who are at high risk
for substance use disorder for example should be Co prescribed naloxone which
is a harm reduction that reduces if somebody is an active overdose can
reverse an overdose in progress so those are I think some of the sort of
high-level takeaways and maybe another one is that opioids for high-risk
patients should not be Co prescribed with benzodiazepines such as Xanax and
Valium but that’s kind of the gist of it I should say that the guidelines are not
rule regulation or law they’re in fact just intended to be just that a
guideline which is to give clinicians some benchmarks to have conversations
with patients what’s gonna work for you what are your treatment goals let’s
dialogue about what makes sense in some cases the the benefits of opioids do
outweigh the risks there are a number of people who do well on long-term opioid
therapy they need to be monitored carefully over time so it’s it’s as I
said it’s not a rule regulation or law it’s intended to simply be a
conversation starter you looted this moment ago but I want to go one of the
elements the guideline that I think maybe gets most overlooked most often is
this idea I think that people see the guidelines potentially is anti opioid
all the time and this decision initial decision of to use opioids are not to
use opioids but one of the recommendations is even in cases when
opioids are prescribed to always pair it with something else pair it with a non
opioid option don’t just rely on the opioids Jones story obviously is a great
example of why to do that what are those alternatives and and how accessible are
they to the general public I mean I think there’s a need for those those
opportunities those interventions to be more accessible I think post-surgery it
does make sense perhaps have a short script of opioids but then if that
absolutely does need to be done in common
with range of therapies from exercise to acupuncture massage yoga cognitive
behavioral therapy a full range of treatment options I think the evidence
base is continuing to build out but the goal should be to improve pain function
and quality of life that that that’s really what we’re aiming for and if you
know I think the physical therapy community is well poised to help deliver
on that obviously immediately post-surgery or an acute event it does
may make sense to have opioids for a short day supply the CDC guidelines
recommend you know three days is usually sufficient for you know a fracture
wisdom tooth extraction longer than seven days again the risk goes up as
dose and duration go up so that’s something you need to be sensitive to I
want to finish this panel by talking to the congressman congressman to across as
you listen to the Jones story first of all what does that sound like compared
to the stories you hear from the first District of New Jersey first of all
thank you for having this conversation we have that bipartisan task force that
has been meeting in over the last two years in Congress because 435 districts
across this country from urban centers to rural areas the stories that happened
in my district are not unlike anywhere else in this country unlike your story
and in many cases in the rural areas where logic of years ago thinking it was
an urban issue is happening too low Mikey down the street is there a
predisposition when they go when they tear it or their knee up and take that
first bill does it trigger something much like your story of your brother hit
him differently than it did you so these are the stories that we hear and I
unfortunately buried it dear friend of mine that low over a month ago who
struggle with the disease of addiction his adult life we see that pain and it’s
a room like this will be discussing this saying you see somebody tear up and you
understand that it goes across all races all economics everybody in this country
has had this story unfortunate in this year we expect the number to be
around 75,000 who will die from disease of addiction through an overdose disease
of addiction something I know you’re very passionate about what needs to
change in this country in terms of if that’s obviously bigger than just
opioids but what needs to change in terms of how we treat that disease well
first of all you’re having this discussion
that’s stigma drug addict oh we can’t help but self-induce if you didn’t take
the drug you would never be a drug addict these are the things that we hear
quite frankly it’s stayed too Union we can arrest our way out of this problem
which is all the wrong message yes criminals need to be addressed nobody’s
going to argue with that but as I was walking up to a dear friend of mine
whose son eight years clean overdose – just one relapse and she’s crying she’s
I should have been able to do something about this I said if your son had
diabetes would you blame yourself there really isn’t a difference it is the
disease of addiction so having the conversations and rooms like this on
Facebook live we have a event back in district where we invited what we
thought were going to be maybe 30 or 40 people and we had close to 250 in the
audience and 4,000 on Facebook live because they’re seeing that it’s
impacting anybody at anytime and parents loved ones friends will do whatever they
can to try to help them and sometimes that’s not enough so we in Congress it’s
our obligation to make sure that we address this issue so coming together
across party lines northern state southern states to have the conversation
this is not a moral failing it’s a disease and the more we understand this
the more we can address it knowing that I might have come in with shoulder pain
I take a pill and it’s going to impact me one way and you impacts differently
so what CDC has done in prescribing guidelines is a great first step it’s
multifaceted all areas we in Congress created
incentives to say for pain management if you address pain management you got a
better score for reimbursements pharmaceutical industry we all have a
little bit of blood in this trail and coming together as a country not blaming
the Attic the pharmaceutical but coming together
to address this is the only way we’re gonna be able to defeat this
so you mentioned Congress has a responsibility to take on this problem
what’s realistic to expect what what could Congress do this year to make a
dent in the opioid epidemic well number one I applaud the president when he
declared it a health emergency I come from New Jersey our former Governor
Chris Christie embrace the notion really taking some very fluid steps to address
it in our state having a conversation putting commercials up on TV talking
about it in real-life terms but just talking about is not going to change it
we have to have the different methods to address it whether it’s through
education but treatment you know this doesn’t accidentally go away you just
don’t wake up one morning saying gee I’m not an addict anymore life goes on its
treatment its chronic and it’s something that you know particularly the harder we
crack down on ways that the abuses whether through the emergency wards or I
lived in Camden New Jersey they could get a prescription New Jersey drive
across the bridge pay $4 toll and get the same script on the other side of
river because we weren’t sharing that information it’s hard to believe in this
day and age we weren’t sharing those are the simple things we can do but as we
shut off one Avenue after another for those who are driving to get that drug
that shrubs a mammal on the street to buy the illicit heroin or the fentanyl
and that’s the skyrocketing numbers were seeing today from the overdoses this is
impacting everybody across the country and to that effort if people are
watching this right now and want the assistance of Congress it seems to me
like at a time when there’s so much too agreement and so much division in this
country this is as nonpartisan of an issue as there could possibly be what
can people watching this do to encourage Congress to come together around this
issue to have unity around this issue and get something done soon well we have
well over a hundred members of this bipartisan caucus and we meet on a
regular basis as you know so for those of you who have suffered or a loved one
or a friend of yours make an appointment with your Congressman or your
congresswoman back in district and give that real story that this isn’t some
urban issue that happens in the dark at night that it happens anywhere I think
those personal stories are so important because they touch so many lives we had
a horrible storm last year in the city of Camden snow was two and a half feet
and the only thing that was working was our subway system and I recall this as
footprints in the snow nothing moving except for those attics coming into the
city and walking through two feet of snow driving them to get that drug that
disease of addiction is killing our fathers our mothers our sons and
daughters and the only way this gets addressed is if we come together and
have a conversation that’s open and honest Patrick Kennedy who has they had
a bill that was signing it alone that talks about parity so the same way we
treat physical injury should be the same way we deal with mental health that’s
been passed some years ago we still haven’t been able to address that
because the finance is coming to play here are you going to pay for this are
you going to pay for this the cost is what we’re seeing in lives each and
every year so that’s why our caucus continues to grow and hopefully come
together and actually put the resources that we need towards us thank you all
three of you for being part of this discussion we’re going to take a
60-second break here to debut a PTAs new choose PTP public service announcement
apt launched the truth PT campaign in June 2016 to raise awareness about the
an epidemic to talk about options for treating pain a PJs first PSA launched
later that year it was aired in 45 states in the District of Columbia you
reach more than three hundred seventy seven million of Americans it received
more than five million dollars of donated airtime tonight we’re about to
debut a PTAs second choose PT PSA after tonight that will be released and
networks nationwide and you could here see this on your TV or hear it on the
radio coming up soon and so thank you again to our first panel and here is the
debut of a PTAs new choose bt PSA every year millions of Americans use
opioids to manage pain pain can be unrelenting overwhelming and
all-consuming so why do so many of us try to manage pain only from the palm of
our hands doctor prescribed opioids are appropriate in some cases but they just
mask the pain and reliance on opioids has led to the worst drug crisis in
American history that’s why the CDC recommends safer alternatives like
physical therapy to manage pain physical therapists treat pain through movement
hands-on care and patient education no warning labels required and by
increasing physical activity you can also reduce your risk of other chronic
diseases pain is personal but treating pain takes teamwork when it comes to your health you have a
choice choose more movement and better health
choose physical therapy headquarters that again was a PTAs choose PT PSA you
can find more about the choose Beatty campaign and move forward PT comm that
PSA and isolation will be posted to social media tour moved forward PT
accounts later tonight so look out for that please share it please help get the
word out there’s also a campaign toolkit it moved forward PT comm slash choose BT
where you can find ways to engage in the campaign I now pleased to introduce our
second panel tonight on your right is Sarah Wenger she’s the associate
clinical professor at Drexel University’s College of Nursing and
Health Professions and then Stephen stano’s he’s the medical director of
Swedish pain services medical director of occupational medicine services of
Swedish Medical Center and the president of the American Academy of pain medicine
and Steven I’d start like to talk to start with you tonight excuse me
opioids masked the pain we talked we heard about the CDC about reducing the
amount that we use them as we look for a new way to approach and treat pain how
much should opioids be a part of it and how do you fit that into a collaborative
model thanks for having me and on behalf of Eric addy a pain medicine as a pain
medicine specialist it’s great to be here and as a rehab doctor I’ve been
working with physical therapists my career and most of us in pain medicine
have so it’s really good to see a PTA making the steps that they want to take
I think going back to your question Grant mentioned the CDC guideline with
regards to opioids and the recommendations the first recommendation
talked about how opioids need to be used in combination with other types of
treatments so you know I think the understanding needs to be that that’s
not the first choice that we have physical therapy exercise we have non
opioid medications antidepressants sleep medications I mean that the patients
have such complex stories and complex needs we’re not going to solve this with
one pill or one type of pill so if opioids are going to be used you know
how they failed other medications or what are the goals for that patient if
we’re gonna use opioids and understand the risk of those and so within that –
once patients are on opioids like you like Randy alluded to
with opioid prescribing checking the PDMP doing urine screens I think where
we maybe made some missteps we’re not appreciating the risk factors patients
have do they have a risk factor and their family for substance abuse or
alcohol misuse do they have a history of pre adolescent sexual abuse or physical
abuse there are risk factors that we can identify and how can identify those
early and then use those risk factors to better treat our patients and monitor
patients and maybe if those patients opioids aren’t gonna be a good option so
how it Swedish are you approaching treating pain in a different way not
just the take a pill and move on way treating in a more comprehensive fashion
well it’s Swedish and you know around the country for a number of years
there’s been what’s called multidisciplinary interdisciplinary
treatment programs where patients in the past those programs that were team-based
approach that have a lot of evidence were mostly for injured workers and
myself and a lot of my colleagues worked with those programs for many years and
it was always kind of a question to us why are we just using this for people to
get him back to work when our pain patients without a work injury have the
same issues interdisciplinary programs like our program at Swedish involves
patients are evaluated first by a physician for a pain medicine specialist
for an hour they also see our pain psychologist the pain psychologist does
a great one-hour assessment of the patients risk and what they’re going
through depression anxiety sleep problems and in our program at least our
program is a modified program patients are enrolled in groups of four and
they’re there five hours a day and they have a round-robin of physical therapy
for one hour occupational therapy pain psychology and relaxation training and
our patients are there three days a week two of the days it’s an individual
one-on-one treatment and one of the days they’re in a group setting and we also
have a lot of education with a nurse educator that does put takes them
through a curriculum about understanding pain pain pathways stress sleep sex and
low back pain has sort of favorite the one that most patients like and and and
I think you know really I think a lot of it is really giving people more tools to
manage their pain I think it’s a mistake to think of this is just an opioid I
always think the opioid itself is a marker that they didn’t have
comprehensive care and so many of our patients are taking opioids because they
got an Angus the oolitic effect from it and I think our previous patient earlier
talked about the stress and everything else going on in their life around their
pain and then get a little reward from taking an
opioid separate from a people unfortunately developed addiction
problems so that’s our program is integrating that and we still offer
acupuncture addiction treatment medication management we have a
procedure suite and we do procedures and injections and those things like
traditional pain clinics so I think the goal is how do you provide what patients
individually need and some of those patients need a team-based approach so I
listen to that I think about Joan’s story and she didn’t get that right or
well she did eventually but she didn’t get that at first and and I asked her
about what the patient’s ability or responsibility was in this and so I hear
you describing that and I think okay if I was in pain that’s sign me up that’s
what I want so what’s the patient to do do we have to find Swedish is that is
that what I need to do anymore maybe my boss would like that he said
nein Swedish so but but you know in other words you know do patients have to
score the country looking for you know the cutting edge clinic or can they do
something independently of that recognizing that they may not have that
health care service in their area well you know I think first you can take a
step back and there’s been a lot in the physical therapy world and I’m setting
up you for this with the physical therapists out in the community
identifying risk factors to start back to all different tools you can use to
identify depression anxiety maladaptive thoughts and behaviors and then tying
that into their assessment of patients so I think early intervention even when
a patient sees a physical therapist or getting a primary care doctor to better
understand how to assess pain and we threw a lot of this to our primary care
providers we’re not trained at all let alone pain a lot of our specialists then
weren’t trained in pain so I think you know there’s that idea of doing this a
better job early on in individual unimodel treatment with physical therapy
or even in primary care clinics on the other side if you develop a chronic pain
problem is your pain provider does that pain person do medical management do
they have a network of physical therapists that they work for with work
with or for do they have behavioral health which has been completely
underappreciated psychology relaxation training when I get frustrated about is
we get patients that start our program and I was involved in a very successful
pain rehabilitation program in Chicago for a number of years it’s a rehab
Institute of Chicago in wherever we were with these types of programs all of our
patients would say why was I given a sooner or the first week of the program
someone taught them how to breathe someone had taught him how to pace some
to set limits with their family members okay things they are doing their whole
life and here we waited three and five years to teach them something like that
so I think do they going back to a provider does that provider have
behavioral health and those interventions that can help teach
patients a lot of this is about education and unlearning kind of a
maladaptive idea separate from you know fear avoidance beliefs a lot of pain
patients can have but also around getting patients to understand what pain
is and really how it affects their function it’s easy to say that but you
really have to take a deep dive and understand that individually with each
patient so you said you were setting up sera and you really did Sarah you
created a model called power over pain and before I have you talk about that
model I want to talk about the goal the goal is the self managing patient define
that so it’s a lot of what Joan said I would say the self managing patient is
someone who’s handling their pain on their own so not necessarily somebody
who has zero pain but somebody who’s managing their pain they have tools they
have the education they need to do what they to sort of use the tools and a wise
we talked about making wise choices they can make wise choices so they’re pacing
their activities appropriately they’re doing things with good body you know
they’re lifting things properly off the floor or not engaging in things that are
making their pain worse and are engaging in activities that help make their pain
better so it’s a lot of what Joan was saying about self empowerment so we’ve
you it’s a little bit of a paradigm shift I guess where we’re viewing the
patient as the person who’s taking care of themselves and then we in health care
serving as their consultants so power over pain the words are really
meaningful to again when we think about how overwhelming pain can be for some
people describe how that model works how do you take people through it how long
does it take what’s involved so we started this a little bit haphazardly we
just we had already had a centering program at our clinic I work in a
community-based clinic we had a centering program for pregnancy and we
treat a lot of people with chronic pain and legalists to say they’re a
complicated and nuanced group of people to treat and so we
we were gonna do centering for people who had pain and get an
interdisciplinary group together so he really just looked at the literature and
did what the literature told us to do plus what our experience what we’d had
to success with in our experience with our patients so we knew it needed to be
an outpatient we didn’t quite have the infrastructure to do like an inpatient
program and we knew that those were successful so we tried to implement the
best we could a lot of the things in those inpatient programs and outpatient
settings so we ended up doing one hour a week and it was just ongoing and you
didn’t have to sign up so we did a very much a no barriers approach where people
could come in it was always there was always at the same time the same week
and patients can come in when they wanted to and if it was raining they
didn’t feel good they didn’t have to and they weren’t sort of chastised for that
um and we do we spent about the first ten minutes doing whatever the education
topic was for the day and whichever professional is the expert on that is
who led the discussion and then the entire rest of the hours really spent on
digesting that and sort of figuring not just do you know this information but
how can you use that information and letting patients sort of figure out how
they were going to apply that information in their lives and there was
a lot of giving each other advice so a lot of group support and when we got
feedback about the program that was something that people enjoyed quite a
bit about it was bouncing ideas off of each other and not just all the ideas
being driven from us so you know patient education we know it’s important we know
that it can have results but convincing somebody in pain that what they need is
just to understand it seems like a leap how do you do that
how do how do you get somebody to believe that this is gonna help them get
better so that’s probably the most common question I get is how do you
actually do that um and I think the answer I think it’s that pain and opioid
use are both very nuanced and complicated problems and everybody has
arrived at them in a different and very personal way and so I think the way that
we approach it needs to be new and very personalized so what I say to
one person is not necessarily going to be what I say to another person I think
when we started our program at Swedish none of our therapists physical
therapists occupational therapists psychologists and relaxation therapists
had never worked in the in a structured program and then as they work together
the PT knows what their psychologist is working on with mindfulness and the
relaxation therapist knows what our occupational therapist is doing with tai
chi’s so there’s this synergy between all of those and I think over time the
therapists get better not just what they’re doing within their their own
specialty but understanding everything else and the patient’s understand that
and that’s what we got the same comments like you this is a therapeutic
relationship and I think that’s been rare because they’ve been given a
medicine and asked what’s your pain score and then they go to some place
where there’s team-based treatment and they’re being listened to and being
respected and they can bounce off like you said the questions that they have so
I think that’s the combination and it’s funny that they don’t tell me when they
finished program thanks for changing my sleep medicine they say wow your team
was really good they really listen to each other they listen to me so I think
there’s there’s something there and I think we can appreciate team-based care
but it’s hard to deliver and we need to get support from payers in our program
insurance companies that we have multiple co-pays and where patients are
paying $200 a day in co-pays so I think there’s a lot of basic things that need
to be done within the healthcare system to really do this we just can’t say
don’t use opioids we have to have other resources and we have to be able to
provide that at all those different levels and I think the when you’re when
you’re telling a patient who’s taking opioids and has pain to stop taking the
pain medicine it is totally counterintuitive for that patient so I
think it’s it’s really about sitting down and having a very earnest
conversation with them you have to build trust and you have to build credibility
I think and sometimes you just have to say look I know this doesn’t make any
sense at all and this is totally counterintuitive but there’s data
there’s research you know whatever what I would I say really varies patient to
patient you know give it a try can we just try it can we can we you know try
it for two weeks see how you feel you can ask me questions but I think it’s
really about like I’m here to help you I think patients really need
understand that you’re not just trying to shoo them out the door because
they’re annoying pain patients you know they really need to know that you’re
there that you’re committed and when they get that feeling they’re much more
likely to hear what you’re trying to say and the truth is is that most people
don’t feel great on opioids so if you’re offering them something else most people
really want another option and if you can get enough air time with them and
enough trust with them to explain that I’ve found most people to be very open
when I ask one final question of both of you and it’s a big question I’ll throw a
disclaimer on it yet again I don’t want to minimize what it means to be in pain
at the same time we have a culture where we want an immediate total fix to pain
from a mild headache to something much more severe is our cultural attitude
about pain part of the thing we need to change Steven I’ll start with you okay I
think and I said it’s a quick once we have to be fast right I mean it’s
definitely more education about it because I think if you think of all of
the commercials everything we’re exposed to on a daily basis is you take your
pill you run down the beach and you’re smiling so and and let pain be your gut
let pain be your guide if you have pain stop I mean all those things we’re
telling them is the wrong thing and you know so I have in some patients we don’t
even ask them what their pain score is you wake up in the morning what do you
do and you walk through and see from a functional standpoint what are they
doing throughout the day so yeah we have to change how we talk to people now for
acute pain maybe your pain score is important I think there’s been as push
that the pain score is not important it’s important in a certain way but you
have to take it in the context of what else is going on with the patient yes so
I would agree with all of that I think I think everybody has pain once you’re
above a certain age everybody has a little bit of pain everybody has a
little arthritis so I don’t think that zero pain is particularly realistic for
any of us I think when you’ve been struggling with pain for a long time
that is just the last thing you want to hear that zero pain isn’t actually your
goal but I think sort of similar to my answer to the previous question is you
have to build trust and confidence in people who are struggling that better
every little step counts you know sort of looking at your small step goals and
not just this far-off goal of perfection I always
say we’re just gonna divorce ourselves from perfection and we’re gonna go for
like if you could do all the things that were important to you
maybe with some pain but not enough pain to stop you would that be good enough
and that would certainly be better than where we are now so let’s just get there
first and see what happens Sarah Wenger Stephen Santos thank you so
much for being here with us tonight we’re gonna take about a ten second
break don’t go anywhere and I’m gonna be back
with our final panel tonight we’ll be right back and once again from the headquarters of
the American Physical Therapy Association Alexander Virginia we’re
back with our panel event and this is our last panel tonight I’d like to
introduce our panelists first to your far right is Bill Hanlon he’s been a
staff physical therapist for seven years I believe working in addiction recovery
at the st. Joseph Institute seven years at the state Joseph’s Institute and then
Tiffani McCaslin she’s a senior Potter sleep policy analyst public policy for
national the National Business Group on health Tiffany I’m going to start with
you the National Business Group on health represents more than 400 large
primarily large employers including 73 of the Fortune 100 who provide group
health and other employee benefits to more than 55 million Americans so let’s
take an issue right let’s take back pain back pain is a common condition that
pushes people into the healthcare system at some point in time back pain leads to
large amounts of job-related disability in this work days those mix work days
are a pressure point for the employee they’re a pressure point for the
employer what can these employers do what’s their opportunity and
responsibility in terms of keeping people healthy and pain-free in the
first place so they don’t have those missed work days so they can go to work
sure thanks for the question and I’ll just start by saying thank you so much
for having me here and also thanks for having this really important
conversation I like many have had a very personal experience with opioid
addiction with someone close to me and my family and it is you know a really
challenging thing to deal with that actually happened about 10 years
ago so it was before there was really all this spotlight on it and I’ve
learned a lot of been very passionate about this issue and since then you know
I think employers have a lot of opportunity to impact this space and to
help their employees you know be healthy and and think about their their pain and
you know their prescriptions in a comprehensive way specifically our
organization worked with the Consumer Reports to develop a non-invasive
guideline for low back pain we’ve also put out employer alerts
to our members to give them recommendations for you know how they
can really talk to their employees about pain
how they can empower their employees how they can reduce the stigma associated
not only with chronic pain but also with addiction and really you know kind of
empower them to seek help when they need it so I think you know there’s really a
lot of opportunity this is an area where employers have been really focused they
have developed centers of excellence within their plan design networks to
really drive patients into you know these multidisciplinary approaches that
we’ve been hearing about here so that an employee can actually have you know a
high-touch experience with some very educated
physicians who are working together to help them avoid you know kind of going
down this path so it’s a lot I probably didn’t cover at all but so this epidemic
really entered the national conversation when President Obama was still in office
and I want to read something he said back in March 2016 he was discussing the
opioid epidemic and he said we have a health care system that too often is
really a disease care system we wait until people get sick and then we treat
them and we don’t spend enough time thinking about how we keep people well
and healthy and balanced and centered in the first place so again keeping people
well in the first place benefits the employee and the employer can employers
big large employers in particular do meaningful things to keep people
healthier in the first place can they be part of it or is it all in the health
care system itself sure you know I think this area in particular is one that
employers have really embraced for a long time I see head shaking already in
the audience probably because you know you you know at your employer you have
Wellness days you have wellness weeks there’s you know employee well-being
programs that are pushed out to employees to really focus on you know
some specific things like diabetes and you know other chronic conditions where
employees really struggle sometimes managing those things on their own you
know I think specific to the opioid issue there are some real opportunities
here as well you know we are actually rolling out this year what we’re calling
a multi session opioid summit and we are really pressing on our
members to kind of take a look at this issue with their eyes wide open I often
say that this issue is a NIMBY issue for employers it’s the not in your back not
in my backyard issue and it’s not because they don’t know that this is a
problem I mean everybody reads the newspaper but it’s a challenging issue
for employers to identify because they’re not clinicians most of our
employers do not employ chief medical officers and this is a it’s a
multi-faceted and complex issue and they can take a look at their claims but
unless they’re really educated on this topic it’s challenging for them to kind
of you know pick out okay well where are my problems and where can we be more
focused so our summit which we are rolling out over the course of the year
is really aimed at educating them around that teaching them how they can comb
their claims databases teaching them to work with their PBMs and their health
plans to implement the CDC guidelines you know the CDC guidelines are fabulous
unfortunately they’re not being implemented and so you know these are
some real actionable concrete areas where employers can have meaningful
impact by working with their vendors so I want to go back to the patient or the
the consumer the employee they may not have individual control over what their
employer offers what would your advice be to them about you know the
conversations they should have with their employer potentially other models
they might be able to show their employer about what might be possible
that’s a great question and I’ve worked in this space for almost 15 years and
when I had a personal issue where I was actually trying to seek help for my
loved one I couldn’t find help anywhere now he did not have a very generous you
know employer plan and so it was a unique situation but I would say that
there are many many challenges around that that need to be addressed there
needs to be a better communication there needs to be less stigma and I think you
know employers can really work with their employee populations and their
supervisor populations to reduce stigma to make that conversation easier but
there are other avenues where employees can find
helped on these types of things like Employee Assistance Programs almost all
luhley is even most you know state health plans on the federal health plan
you can call your Employee Assistance Program and you typically have you know
a set number of consultative hours where you can talk about you know these exact
kind of things it’s wonderful thank you so I want to introduce now our final
panelist and that’s bill Hanlon bill you you comment this from a slightly
different angle you have seen over the last several years in your role you’re a
staff physical therapist in addiction recovery so you’re seeing people not
necessarily because they’re in pain and pain led to addiction you’re seeing
people who are addicted and trying to recover from that and some pain that
might result the first question of when asked is a basic the simple one when you
listen to Joan’s story the story of her the story of her brother-in-law does
that sound like what you see every day what what do you see every day
especially as it relates to the opioid epidemic
yeah Joan’s story is very similar to what I see every day and the patient
stories that I’ve heard over these seven years patients have surgeries they have
pain they get on opiates and they can’t get off them and I see the patients when
they’ve been addicted for some time and then getting them off of opiates what do
we have to offer them that can help with their pain help them manage their life
and a lot of the things that were mentioned earlier we have yoga we have
physical therapy we have acupuncture we have massage therapy we have counselors
we have psychologists we talked about their pain we engage them to have
control over their life and their pain again when for a long long time they
have not I always hate to generalize err or boil it all down to one experience
but when someone is getting over an addiction is is pain common you know in
other words I usually people I think think about the problem itself the
disease of addiction itself what sort of pain are they experiencing from that
alone not just not using whatever they used but going through that experience
yeah if someone doesn’t hasn’t had multiple surgeries and doesn’t have a
disease process that causes pain they still have pain when they’re coming off
of opiates they have so cramping they have belly pain they
have nausea they’re uncomfortable and they need a team of people to help them
get through that and realize this pain is is manageable and we actually see you
know in the first two weeks an increase in pain if they have musculoskeletal
pain that then diminishes over time as they enter into the interdisciplinary
care and are talking to the counselors and working with the physical therapist
and doing yoga and all the things that we offer as a team to help them and and
it really does work and people that never thought I can live without opiates
they just thought they would be on opiates the rest of their lives are
opiate free and doing well they may not be pain free but it’s very manageable
and they’re more active and functional than they’ve been in years so earlier we
addressed sort of one of the elephants in the room which is cost right high
co-pays right now potentially for some of those opioid alternatives and art
alternatives and we need to change that the other one and it goes hand-in-hand
with cost is time so if you’re gonna see multiple people if you’re gonna go a
different way it may take a lot of time so first of all you know how much time
does it take to go through a process like this to emerge on the other side
being able to manage your pain what should people expect well our program is
a 30-day model and it it does take you know several weeks to see that change in
pain but within 30 days most of our patients have a very manageable and and
many a low level of pain but it doesn’t happen overnight doesn’t happen in two
or three days but over several weeks they see a huge difference so we talked
about you know changing the culture around pain and again that idea right
now we want a quick fix we want an immediate remedy addiction like pain is
something that generally does not have a quick fix can can we learn something not
that we’ve mastered addiction recovery necessarily but can we learn something
in managing pain in the way that we approach addiction yes I think the way
that we approach addiction needs to be multidisciplinary just as
the management of chronic pain needs to be multidisciplinary and as we get all
the disciplines involved and understand the psychology of the person who has the
addiction and that disease then we can help them more and more and they they
tend to do well in a multidisciplinary environment but I’ve talked to so many
patients who tried to get out of their addiction on their own and and failed
and then went back and then overdosed and you know ended up in the emergency
room several times and so it’s really really difficult if not impossible for
them to do it on their own but with a team of professionals working with them
it’s very possible please you know we are ten percent of
the world’s population and we consume 90% of all opioids in the entire world
so I think the question is there an opportunity to change the culture is a
no-brainer you know there are countries where patients leave you know after
having an outpatient surgery with no opioids none they never get
prescriptions is that the right thing you know I don’t really know the answer
to that but I certainly think that where we are is the wrong thing and that is
you know another space where our employer members are very focused is
sort of changing this culture of how we think about pain and the necessity to be
pain-free because it’s you know often not a realistic expectation that’s a
great point and bill before this event we were talking about attitudes around
pain and you mentioned you see a lot of people who knew your words spent two or
three years getting into a problem and expect to get out of it in two or three
days under that’s not realistic likewise we hear a lot of times related to other
injuries you know somebody will tell the physical therapist do I have to do this
exercise forever and it’s like well is it working and you want it to be part of
the solution it might be a good idea how you know how do we get people to believe
in this idea that they need to commit to their health day and day out and that
some of these problems may take a day in and day out commitment for potentially
for the rest of their lives yeah and it’s it’s communicating with
people it’s talking to people and letting them experience the Wellness and
experience EXOR sighs that doesn’t increase their pain
and experience sleeping better because the doc is working on their sleep
medicine and patient is doing the exercise you know that’s been prescribed
and they’re sleeping better which also helps with pain and it gives them a
better quality of life and they’re eating better because off of opiates
people enjoy their meals more and have fewer GI issues and they experience this
wellness and they experience lower pain levels and then they they want to
cooperate with it because they see that it’s working we could talk about this
all night unfortunately we can’t so we’re gonna close out thanks again for a
final panelists and thank you for everybody watching online just to give
you a preview of some things coming up from a PTA later this month a PTA hopes
to release a white paper outlining recommendations to address the opioid
crisis in May pgj a PTAs official scientific journal will spell published
a special edition on pain you can find those articles publishing online ahead
of print and late March in June a BJ’s member magazine PT in motion will have a
feature article on the opioid epidemic and in the meantime you can go to move
forward PT comm slash use BT learn more about the ways that physical therapists
can help that includes a patient profile it is a document where you can talk rate
the pain you’ve been having rate some of your past experience and bring that to
you when you talk to a doctor so you can have a conversation about the pain
you’re feeling and the kind of treatment you want to have I would encourage
anybody to download that last thing finally this event doesn’t happen
without a lot of help from a lot of people thank you to support from
multiple hey PJ staff but especially Alice Bell Kari gainer Gibran Ishmael
Lilly Schlatter wick Mike Matlack and Don Paulson we’ll be posting this event
in full to YouTube and Facebook tomorrow again you can find the choose PT PSA
posted to the move forward PT accounts later today please share this video from
this panel there’s a lot of great information here we’ve learned a lot
tonight let’s extend that message out because we have no doubt that someone
near you is having this problem whether you know it or not
I’m Jason Bellamy thanks for being with us tonight

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