“What is true isn’t always popular, and what is popular isn’t always true” ……Howard Cosell
In the past few weeks, my travels have included conversations with many PT’s who are very excited about the recent CDC guidelines on prescribing opioids for chronic pain. The suggestion that physical therapy is the right and correct replacement while encouraging is an illusion at this stage. As I pointed out in my last post, in 1998 there were over a thousand multi disciplinary clinics practicing a biopsychosocial approach to chronic pain and likely having great outcomes. Within 7 years, this was reduced to approximately 75 locations. Why? Payor policy. Just because we have CDC guidelines now, doesn’t mean this trend will quickly reverse. In fact, here are just a few reasons:
–Insurance companies: Payor’s are not motivated to expand reimbursement policy under any circumstances. It is just easier for a payor to justify paying less for something than to pay for something that is likely better but involves more services-after all they are motivated to save employers money remember? Chronic pain patients will always be cumbersome to a primary care practice such that a “new, non addicting” pharmacologic agent will likely continue to be the treatment of choice (medical marijuana?) rather than a significant rise in physical therapy and other services.
–Marketing outpacing training: A sudden rise in multidisciplinary clinics with physical therapy as its core will crop up and will be more marketing than substance. We are already seeing PT wannabe groups sending few PT’s to weekend pain science seminars and now suddenly all of their clinics are fully “certified” in pain science. Tell tale sign of this will be a temporary rise in PT referrals to “pain PT specialists” that may get less than stellar results due to inadequate training and thus do more harm than good for our cause.
–Opportunistic physicians. There are a number of physician types-anesthesiologists, internal medicine, physical medicine pain specialists, and neurosurgeons that are also seeing the CDC guidelines as an opportunity to expand the breadth and depth of their services.
In my view, for physical therapy to have any success, we have to admit treating chronic pain is not at this time an entry level competency. A shift in emphasis from manual skills to tacit knowledge skills will have to take center stage. A broad acceptance and understanding of social neuroscience, cognitive behavioral techniques, appropriate use of meditation, and in particular communication skills will need significant enhancement and emphasis. This is not to suggest that manual skills are unimportant but we have to rely more on “neck up” skills in order to maximize our opportunity afforded by the CDC guidelines. The numbers of patients with chronic pain are rising to epidemic proportions and we have to be able to access more than 7% like we do in low back pain. The challenge is on-will we rise up, collaborate with other professionals, or will chronic pain clinics simply be the work hardening centers of this decade?
Thomas Frieden, the director for the CDC was thoughtful in his words on the day of the release of the CDC guidelines, “When Opiates are used, start low and go slow” he advised. Perhaps as PT’s we should also heed this great advice if we are to have long term, sustainable impact on patients with chronic pain that need us.