Are We Getting Less and Less for More?

There have been a number of interesting big picture papers recently released in the world of musculoskeletal medicine that both identify great opportunity for the profession of physiotherapy. This stated, we also have some significant hurdles we need to overcome in order to move forward. What are some of these papers?

JAMA just published a detailed paper on health care utilization in the United States (ref) and the results are mind boggling. It is estimated that the United States spent $30 trillion on health care over the last 17 years. Let that sink in for a moment, $30 TRILLION dollars. Even more stunning is the average amount spent per person in 2013: over $9,000 dollars. The cost of care per year for the treatment of neck and low back pain is estimated to be a staggering $87 billion dollars, more than that spent on cancer and third overall, behind diabetes and cardiovascular disease. Furthermore, between 1997 and 2013, there was an annual increase in spending on neck and low back pain of 5.4% - that’s right, not a 5.4% increase over 17 years but a 5.4% increase average each year.

 

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Some of this cost might be ok if there were some actual improvements in people’s disability and pain. Most research suggests that for all the money spent and the modernization of medicine, rates of disability and pain secondary to musculoskeletal causes have increased over the last twenty years (ref). All the imaging, surgical interventions, medications and yes, even physical therapy really has not improved this situation.

Let’s take the use of opiates for pain management of low back and neck pain as a failed intervention. First off, Tim Flynn has done a far better job than I could ever do reviewing the use of opiates for musculoskeletal pain and I encourage everyone to watch his presentation on this topic here. This stated, the opiate problem is so widespread and dangerous that it is worth visiting again from a more local perspective. I live in British Columbia, Canada with a population of about 4.6 million people. Although our country does not prescribe opiates as widely as the United States, we are sadly the second highest prescriber per capita of opiates, writing one prescription for every second person in Canada each year (ref). So, how bad is the problem here? Last year, nearly 1,000 people died as a result of overdoses in British Columbia (ref). There were so many overdoses that first responding fire departments in Vancouver’s east side literally were unable to do anything else – they attended to 1,200 overdoses in the month of November (ref). I think it is worth considering these number as just the tip of the iceberg. For every person who overdoses, how many more have their lives turned upside down by addiction? How many jobs are lost, relationships destroyed or dreams lost to addiction? In the United States, it is estimated that 2 million people are addicted to prescription opiates and I can only imagine the suffering that occurs for the individuals addicted, their families and their friends.

we have an intervention with modest effects that are short lived, carry significant risks including death and likely actually worsen pain over the long-term and they are prescribed ubiquitously

At this point, I am sure that some are questioning these numbers and if all of these deaths and overdoses are secondary to prescription medicine. Some recent research suggests that two thirds of all deaths related to opiate overdoses started via well intentioned prescriptions for benign conditions with patients switching to street based opiates that are less expensive and more readily available. Even if the percentage is much lower, what is an acceptable risk? It is worth considering that there is some moderate quality evidence for short-term pain relief with opiates and low quality evidence for improvement in function (ref). In fact, no long-term trials have been performed with placebo for opiates and low back pain. Recently, the journal Science published an article suggesting that there is risk for opiates causing hyperalgesia with prolonged use (ref). So we have an intervention with modest effects that are short lived, carry significant risks including death and likely actually worsen pain over the long-term and they are prescribed ubiquitously.

The Surgeon General took the unprecedented step of mailing over 2 million health practitioners to help “Turn the tide” of the opiate epidemic. Here, he recommended ways to curb opiate usage and I can happily report that one of his recommendations was to suggest not to prescribe opioids as a first line intervention for noncancerous pain. He went even further and suggested considering exercise, physical therapy and cognitive behavioral therapy along with a number of alternative medications. The fact that physical therapy and exercise are mentioned should be rejoiced but we should also be concerned that exercise is not considered an integral component of physiotherapy. Also interesting is how this epidemic has identified massive gaps in the education provided to clinicians to treat pain. Apparently, veterinarian students get far more education than any health care provider in the management of pain as mentioned in a Canadian study of pain education (ref).

So, what can we do to propel our profession to the forefront of musculoskeletal management and avoid the pitfalls of medicine’s present approach to musculoskeletal pain? With low back pain, there is research that accessing early physiotherapy leads to less surgery, drugs and costs (ref). Sadly, our physiotherapy is massively underutilized, with most episodes of low back pain never being seen by a physiotherapist. From a bigger picture perspective, we need to more actively promote our profession and its ability to decrease cost and improve health outcomes.

But are we as physiotherapists providing the best possible care for our patients or are we falling into some of the same traps that lead to the overutilization of opiates? Has our mindset as a society contributed to the problem? From a day to day basis, we need to move away from being a provider of physiotherapy as a service and act more like a primary care profession. This means not seeing each case of low back pain that walks through our door as a dollar sign that requires x number of visits three times a week. Many of these cases get better and need an assessment to rule out significant pathology, reassurance and education on remaining active with a follow-up visit. Our expertise is not based on our ability to provide an intervention but rather in determining the appropriate intervention for the appropriate patient. This means recognizing the patient that will need more care to prevent ongoing disability and pain and focusing our efforts on these patients.

We also need to move away from magic bullet cures for patient’s pain – but in doing so, do we become part of the solution or part of the problem? With low back pain, we quibble about the efficacy of dry needling or which manual therapy treatment is best. Don’t get me wrong, I use these interventions but they are never the main focus of treatment. They are simply tools to help decrease pain in the short-term and begin activation through exercise. Unfortunately, as well meaning health care providers, we often fall into the same trap that physicians who prescribe opiates or surgeons who perform spinal fusions. We all want to help people with their suffering and do so quickly and for the most part, patients want to do it with the least amount of effort. And although our interventions typically don’t lead to addiction and overdoses, quick fixes rarely work and all too often when patients fail with these types of approaches, self-efficacy is lost and patients end up on a road of dependence and disability.

There is one other part of the Surgeon General’s message that particularly resonated with me and I think it has been under appreciated in medicine. He states “And we need to be willing to grapple openly and honestly with the fact that we have paid too little attention to the physical and emotional factors that are driving pain for millions of Americans”. Where have we gone wrong? I think this statement really is a call to reflect upon the complexity of pain and our approach needs to look at our patients from a much broader lens. Looking at the whole person from a biopsychosocial lens and how relationships, beliefs and emotions are important factors in our patient’s pain experience is an integral component of how we can better help our patients learn to manage their pain. Perhaps even more importantly, it speaks to how a significant component of our treatment effect may be based on our ability to create a therapeutic alliance with our patients (ref).  

It is interesting that perhaps part of the solution to the complex problem of rising health care costs, invasive surgeries, medical scans and potentially dangerous medications are very simple changes: Caring professionals that educate appropriately and stress the importance of an active lifestyle in the maintenance of health.