An Osteopathic Approach: My vision for how Osteopathic Physicians can help decrease the Pain Pill Epidemic
Introduction:
Opioid addiction is rampant. In America alone, 21.5 million people have a substance abuse disorder. It’s crazy—47,000 deaths in 2014 were attributed to drug overdoses, with the majority from opiates like heroin. While some of these drugs are obtained on the streets, many addicts will say that they first got addicted from prescription “pain pills.” In 2012 alone, there were 259 million prescriptions for opiates. In other words, this was enough for every American adult to have a big bottle of “pain pills.”
I can see how it all started. I mean... opiates can be very beneficial, especially for acute pain. If someone has a broken hip, it is very reasonable/beneficial to prescribe an opiate for a short duration and then decrease that dose until terminating that medication. If someone has chronic pancreatitis, sometimes that pain needs to be properly managed with opiates.
However, diseases like fibromyalgia, psycho-somatic pain disorders, and other chronic pain disorders are simply not well managed with opiates. It is known now that opiates lower the threshold of pain. It depletes the body of endogenous endorphins, which makes the patient have less tolerance to pain over time.
Many with chronic pain disorders have psych-related issues that manifest physically. For example, a woman complaining of chronic pain may have “tight” paraspinal muscles that are physically evident, while not having any vertebral pathology seen on MRI.
These tight muscles could be partially voluntary muscle contraction…basically they are actively contracting their muscles. At the same time, those muscles could be "tense" due to hormone changes and hyper-sympathetic nervous system stimulation, which can both be triggered by emotional factors. The woman in this example may be depressed, had a traumatic childhood, or have no such history. One thing that I firmly believe is that there is often a major psych related component to these issues.
When a depressed person with chronic pain takes an opiate, he or she will feel relief... an escape from physical pain temporarily, and a transient numbing of his or her psychological issues. However, this is not treatment; it is transient. It is only postponing the furthering of this problem.
As a 4th year medical student, I see how hard this issue is in the hospital and in the clinic. It is much easier for the non-medical community to say, “stop prescribing all opiates!!!” but this can be dangerous too.
For example, let’s say someone is clearly addicted to prescribed opiates, which at one point they needed to be prescribed them. If a doctor told them that they would not prescribe them any pain medication and to see a pain specialist, that patient may leave in anger, pick up the heroin, and arrive at the emergency department dead! Pain addiction treatment has to be done slowly and methodically.
Personally Seeing a Man Die of an Opiate Overdose in the Emergency Department
I remember the first time that I witnessed someone die from an opiate overdose, and I remember the reaction when I had to tell the family that their 40 year-old father was dead. I was doing an emergency medicine rotation when the ambulance arrived. It was a 40 year-old man who was found not breathing in his car with bottles of prescription opiates. He had no pulse but a shockable rhythm, and I began chest compressions.
We shocked him a couple times and gave him some epinephrine and Narcan. In minutes, we did get a pulse back. Thoughts came rushing….we have a pulse but is he brain dead?….how long had he been without oxygen to his entire body?
The process went on, and for over 30 minutes we battled to save this guy’s life. Eventually, there was nothing left to do. His heart gave out, and the overdose had killed him. When his family arrived, they looked calm—like he had been through this before. One daughter asked, “what did he do this time?” It was hard seeing this guy die, but it was on another level to have to tell his loved ones he was dead. There are just some things that will stay in my mind forever—that was one of them.
My Vision on how Osteopathic Medicine can Help
There are now regulations in place to stop the overprescribing of opiates. However, this should be done methodically. Basically, we try to lower the dosage of the opiate to prevent withdrawal. For chronic pain patients, we may prescribe them gabapentin for nerve pain and Flexeril, a muscle relaxant. We may try antidepressants to treat other components that may be manifesting as physical complaints. Physicians may also try to consult other specialists such as psychiatrists, psychologists, physical therapists, and pain specialists.
These are all good efforts to try and decrease the pain and addiction of these patients. For those that are not addicted, it is a good way to help treat these conditions while preventing addiction. Finally, physicians can also refer patients to pain specialists who often have contracts with their patients to prescribe opiates while also drug-testing their patients to make sure they are not diving further into pain addiction.
However, one problem that I have seen a lot from these patients is a lack of trust. They feel like they are being “thrown” from doctor-to-doctor because no one wants to deal with their concerns. I don’t believe this is usually the case. I think the actual reason is that their condition is hard to manage. There are only a handful of non-opiate pills that can be offered, and there are layers of issues surrounding a patient with chronic pain. A multi-team approach is better when there are multiple issues.
Through all this darkness/lack of hope, I believe that the field of osteopathic medicine could be one potential step forward in improving the lives of patients with chronic pain problems that seek opiates.
In osteopathic medicine, we learn to treat the whole patient—not just their physical pain but the emotional factors that also contribute to their problems. In addition, we have skill in manipulation which could negate the need for physical therapy. We are fully licensed to prescribe any medication, but sometimes a medication just won't fix everything.
Physical therapy is great, but the problem is that many of these patients think you are “moving their problems” to someone else. By keeping the patient with one practitioner as much as possible, more trust can be established. This is a hopeful outlook. This problem is increasing by the day, but I feel it is a step in the right direction.
A Hypothetical Example of a Chronic Pain Patient Seeing an Osteopathic Physician:
A 35 year old female with hypertension (high blood pressure) and chronic neck and back pain comes into the clinic with the complaint of “hurting all over!.” She is divorced and has no family support around her. She currently takes Lisinopril for her blood pressure and Norco for her back and neck pain, which has helped, but the pain comes back as soon as the medication “wears off.” She just wants help with controlling her pain. When asking about her mood, she says she is fine, doesn't care about any of that, and just needs her pain controlled. She is a new patient here and is sick of her “old doctors” telling her to take SSRIs and muscle relaxants. She finally found one doctor who gave her Norco for an acute pain she was having but she just ran out of her medication yesterday.
This is sadly a very common scenario. It is frustrating for the doctor and patient. The doctor knows that this opiate is making the patient dependent. The physician also knows that it is furthering the problem by decreasing her threshold for pain. It is also frustrating that the patient has turned her back on alternate ways for pain control. What is the doctor supposed to do?...ask the patient again for these alternate methods in hopes that the patient will change her mind?
Perhaps that is an idea. The other factor is that this patient is likely depressed, which could also be intensifying all this pain and making the quality of her life terrible.
Although I have more limited clinical experience, a year and a half in hospitals and clinics has given me some ideas as a senior in medical school.
Firstly I think this person’s mood is a major factor that needs to be addressed. This person just from the above description appears depressed. She is not demonstrating she is “sad” but she does seem to have anhedonia, a lack of pleasure in everything. This is one of the other clinical criteria for major depression. This patient would benefit from having a discussion about her emotions, a possible referral to a psychologist/psychiatrist, and another offer to receive antidepressants.
If the patient still objects to drugs like SSRIs, there are other options. If medication is not something she is willing to help with her mood, then consultation with a psychologist might still be a way to control her mood. People who are depressed, will have more chronic pain and are also more likely to stay addicted to drugs. In addition, it just makes people feel rotten!
I would then do a physical exam and make sure that there did not appear to be something structurally and pathologically wrong with the patient.
Then I would look for somatic dysfunction (look at my osteopathic post on this at the link here). If I found some, I would ask the patient if she had ever had osteopathic manipulation... If the patient agreed, I would try to use different techniques to relax her muscles and hopefully decrease her pain while also increasing her functional mobility. I would tell the patient beforehand that my goal is to decrease the pain, not to magically get rid of it. If she had a pain of 10/10, a 4/10 would be a great milestone. Decreasing pain and learning to live with some is an important mindset to have with patients.
I have seen the powerful effects of osteopathic manipulation on multiple patients with chronic pain. I have seen patients come into the ER with chronic pain issues in hopes of getting opiates to relieve it. I have performed OMT on many of these patients who walk out not only with less pain, but THEIR MOOD seems to be better too.
There is more to OMT than helping physical pain. I personally, believe that many psychological factors are sometimes manifested physically because the patient can use it as a “coping mechanism” subconsciously. By fixing the muscle or joint, you can hope that the emotional component gets “brought to the surface” and the patient feels like a “load has been lifted.” This is only a theory, but I believe it. I have seen the power of a change in mood after performing OMT. If anything, using two hands to try and help a patient brings significant emotion about caring for them. This is just as important as the clinical effectiveness of decreasing pain with OMT.
As a future doctor, I would also try to help this patient by making sure her blood pressure was controlled with her Lisinopril and hopefully decrease her dosage of prescribed opiate medication. I would tell the patient that we would work towards stopping this medication slowly, while helping to control her depression, blood pressure, and perception of pain.
Although many circumstances make this example much harder than presented here, I think this is the right mindset. The addiction to pain medication has tripled since 1990, and hopefully with better approaches, we can cut back on this terrible epidemic!
Thank you, and I would be happy to entertain any questions or comments.
Feel free to follow!
Sources
See above link to stats. All photos from Pixabay.com and no sources are necessary but links are provided. Most of this information besides the stats are my personal experiences, ideas, and theories that I learned in my medical school.
ME!
Outstanding post! I learn a lot from you and will continue to follow your blog.
Much appreciated. Thank you for taking the time to read.
Nice article! Thank you for taking the time to write this all for us!
I am glad you enjoyed the read!
The dangers of becoming addicted to opioid pain killers is much greater than many people realize. The message of this post is one that we should all get behind and we hope that everyone on Steemit takes a moment to read about. The coverage of opiate prescription in this post is well balanced discussing both the double edged sword of issues with addiction and increased sensitivity to pain, but also that they are needed for the treatment of certain types of pain/ailments.
Thank you! I am very happy with the reception this post has brought to people. My vision is not perfect because it is such a complicated issue. Steps in the right direction will hopefully have a positive impact on a growing problem! I look forward to continuing posts of this nature and those on general health topics.
Wow, great post @tfeldman. It's interesting to hear your perspective on what its like to be the person tasked with prescribing the opiates, and how you recognize how much an issue it really is.
By the way this is a fantastic, detailed and very informative post. Its a bit on the long side but I hope people look past that and really give this a read.
Thank you! I have been looking forward to writing this post. I envisioned it being shorter, but I think for how complex the issue of chronic pain is, it was about as concise as I could be. Thank you for reading, and I appreciate your support for my new blogging hobby!
Outstanding post! As usual ^^
One current paradigm (at least here in France) is that a 'good physician' (note the quotation marks) is someone who gives you pills when you are not all right. This goes very along the lines of your text...
Now a question, would homoeopathy something you would recommend?
Osteopathy is a pseudoscience. It is peculiar that @justtryme90 resteemed it :-)
https://www.sciencebasedmedicine.org/osteopathy-in-the-nicu-false-claims-and-false-dichotomies/
Guys, you need to do some research first before believing such anecdotal "evidence".
I resteemed it because it is a good post, and I fully stand by my decision to do so. Perhaps you should try reading posts before you go around trashing on them. I am not impressed with your behavior here @logic.
I appreciate the reposting!
Wow.
I read the post. It is pseudocience. The author evedn admitted in his comment/repy to me that it is purely hypothesis and there is no scientific research to back it up.
Instead of getting all offended (as it seems that you did) by my direct criticism and retaliating with stubborn reaction, it would be just easier to admit that you may have made a mistake and have been wrong about this.
There is nothing wrong in making mistakes (as opposite to what majority of society telles you). That's part of learning process.
Scientific method is based on making mistakes.
Since I can't reply below I will post here.
My point is that relaxing muscles through muscle energy is science haha.
There are muscle spindle fibers that when activated send neural signals to the spine which contract one muscle and activate another. Studies have been done on this as mentioned in my last osteopathic post. In addition, these physiotherapy methods also increase blood flow to the muscle in treatment and decrease pro-inflammatory cytokines as mentioned in my prior osteopathic post.
Basically, relaxing a muscle group IS science....if you ask how a muscle group relaxes with the technique?...that is the science.
You didn't read my comment clearly. I said that all the theories about chronic pain is not well thought out by MDs as well. We all just have theories and things that need to be tested. That is what the scientific method is about. Thinking of ideas and testing them. The testing stage needs to be done for anything. The only theory is why depressed people have somatic complaints. It hasn't been tested well anywhere.
In the face of that there is an active problem. When someone is in pain you can't just tell them...sorry to hear come back when the scientific community has fully tested all these theories. If something will not harm a patient, it is better to try than to leave them in pain.
I think it takes a true medical professional to fully understand the dynamics of a patient. Patients are more than research, they are people.
For instance, epinephrine during cardiac arrest has not been shown to decrease mortality in cardiac arrest patients. However, it is in every medical guideline to sill do it. Sometimes trying to save a life is more than just statistics. If you had a loved one dying I'm sure you would want every effort possible to save them no matter how strong the evidence was of its true benefit.
I doubt that you have been in these situations. Sometimes experience is an important part of maturity.
If this alternative method helps them (because of placebo effect, or becasue of their psychological need for relaxing tough) then it is fine. No one should prohibit them from trying alternative therapies.
The problem is when these alternative therapy practitioners tell the patients that it is something based in science, and is something more than just relaxing or physiotherapeutic method.
I guess this is where I am supposed to defend my field...I always encourage comments, even from those that believe that it is a pseudoscience. I do encourage you to read my previous osteopathic medical posts, as I try to help bring clarity to the profession and general criticism.
I kindly disagree with your broad remark that osteopathic medicine is a pseudoscience. The understanding of homeostasis-- that the body self-regulates itself....the reason why our temperature stays the same while the temperature outside changes is a great example of this. That structure and function are inter-related is common sense and understood. The reason that we have paraspinal muscles that allow the body to remain erect as we walk is commonplace. This is science.
Osteopathic medicine is much more than OMT. It is about using the above scientific principles to improve health. An increase in health does not need to be performed with OMT. It could be by prescribing different medications, or performing surgical procedures on someone like MD and DOs do.
All OMT principles, which again is small compared to what all osteopathic physicians learn, is one tool that can be attempted. In situations like chronic pain, MD and DOs alike don't have many answers. We don't understand the disease process well enough to fully treat it. When the medical community is lost for answers, theories are made. MDs and DOs have proposed many physiologic theories as to why it happens without much evidence based research. To the same end, I proposed theories which I believe to be the case. We can call this a hypothesis. That humans subconsciously bury their emotions by carrying that "weight" as a physical burden is not evidence based. As I stated in my article, "it is only a theory"...I have not tested this hypothesis. However, I would hypothesize that if enough money and time were put into studies of this nature, I would stick with this being a likely cause.
The link you provided was from an MD who was very critical of 1 OMT study. There are many studies in the non-DO world that I could criticize too. The study regarding electronic cigarettes published in the NEJM, which found high levels of formaldehyde in the vapor was a terribly conducted study. I am not advocating for the safety of these substances, but when a study heated the coils to much higher temperatures than any user put them at, the study was a poor reflection of the potential harm to users. The point here is that even "mainstream" studies recognized by the medical community are often biased and poorly designed.
I would probably agree with you that much stronger studies need to be done on the effectiveness of OMT. One problem is the lack of funding for the study size/ properly controlled studies. I do respect, despite the lack of financial support, the pursuit my profession gives to test our scientifically based theories.
On a side note, I believe that it is also important to point out that when we do OMT, we conduct a physical exam before and after the technique. If someone has pain in a muscle area and I can feel differences in the texture of the tissue being palpated that is an objective finding. If I perform a technique and the pain is alleviated while the tissue texture change is now symmetric with the non-painful side, that is strong physical exam evidence that the technique did improve the patient.
Physical therapy is also a specialty that the mainstream has accepted as viable resource to patient recovery. They use and share many elements of OMT in their practice as well.
I encourage you to have OMT performed on you at some point. I think maybe you would be surprised at how practical and logical it is. Not to mention, I bet you would feel a lot better ;)
Hijacking medical terms in order to make this field look more legit won't make it less pseudoscientific.
There is no evidence that this therapy works beyond placebo effect.
Also simple touching someone in caring way (like in massage) may cause someone to feel psychologically better and so have psychosomatic effect. That's about it
Training as a medical professional I'm not sure where I'm "hijacking" these medical terms from.
Bold claim that every study is placebo effect. I'm sure that you reviewed every osteopathic study ever.
If I do a physical exam on someone who has a contracted hamstring on the left leg and can only bring the leg up about 30 degrees....then after doing a technique move the leg 48 degrees... what is the placebo in that? I see very objective support for this claim. I can even provide videos with physical evidence for you to see with your own two eyes if that would calm your nerves.
I don't know what field you are in, but I have serious doubts about your credentials to confidently make the claims of pure pseudoscience.
Before my medical training I also majored in biology and am well aware of scientific theory/method.
I can see your animosity towards our profession, and I will continue helping people. I'm okay with a difference in opinion, but you do appear to have lots of frustration.
"Bold claim that every study is placebo effect. I'm sure that you reviewed every osteopathic study ever"
I don't need to study all osteopathic studies. I trust the consensus opinion of medical-scientific experts:
http://www.nhs.uk/conditions/Osteopathy/Pages/Introduction.aspx
"If I do a physical exam on someone who has a contracted hamstring on the left leg and can only bring the leg up about 30 degrees....then after doing a technique move the leg 48 degrees... "
It sounds like a simple physiotherapy technique. Osteopathy can certainly have physiotherapeutic effect. That's about it. I don't disagree with that.
"I don't know what field you are in, but I have serious doubts about your credentials to confidently make the claims of pure pseudoscience."
Appeal to authority - logical fallacy.
"I can see your animosity towards our profession, and I will continue helping people. I'm okay with a difference in opinion, but you do appear to have lots of frustration".
As long as you describe it for what it is - certain type of massage which can have relaxing (affecting the psychology), physiotherapeutic effect or placebo effect, then it is fine.
The problem may start if you ever start claiming then it is more than this.
Good luck with the practice
Okay man. I only pulled the "what do you study card" because you made pretty bold claims, that I find has limited support. Even the article you attached said that osteopathy helps with low back pain. A physiologic effect is what I am talking about in this entire article. Decreasing chronic pain in physiologic tight muscles while also improving functional capabilities. I wasn't saying I was curing cancer haha.
Ok, then I'm sorry about my harsh criticism. I had an impression that you are attempting to claim something more than physiotherapeutic/relaxing effect.
Thank you for the kind remarks. I think that a good physician should take care of the patient to the best of their ability. However, what the patient wants is not always in their best interest. Medications will often be the best option....but opiates and chronic pain is not one of them!
On homeopathy....I am not an expert in this field so I do not want to give unwanted criticism to a field I have not witnessed first hand. However, from reading a little about them there are things I like and dislike.
I like their holistic philosophy and their like understanding that the body through homeostasis is self-regulating. I imagine that some of their treatments could be beneficial.
I am a bit skeptical about their lack of evidence based research and the fact that they only believe in natural remedies. There are plenty of "man made" synthetic drugs that have done remarkable things for patients. There are bad synthetic drugs for sure. There are also bad natural things. I wouldn't swim in a pool of mercury, and I wouldn't eat a bunch of toxic mushrooms. They might not either haha. I don't know if I agree that "like" treats "like" all the time. However, snake anti-venom would be a good example of when that is the case!
Like all treatments, if the patient is not harmed by a therapy that I can foresee and they feel a benefit that is not too financially burdensome for them, I would not discourage it.
Thanks for taking the time to answer me. I am actually kind of interested by any option that could be complementary (I said complementary) to more traditional medicine. Being very busy simultaneously, I unfortunately do not spend enough time reading about that.
osteopathy is bollocks. pseudo science.