Second Opinion: Physical Therapy for Chronic Pain Is a Viable Alternative to Opioids
讨论痛苦时和阿片类药物的使用，有一些重要的事实需要考虑：
根据2011年的数据，来自医学研究所（IOM）的报告，美国中美国1亿人患有慢性疼痛。之后的报告显示这个数字更接近to 50 million.
许多医生承认“痛苦”第五生命体征（血压，脉搏，呼吸和温度）
许多研究阿片类药物安全（包括成瘾）概况的制药公司在持续了大约三个月的研究中确实如此。
广泛使用阿片类药物来治疗疼痛始于1980年代，，，，and in 2010, according to the Centers for Disease Control (CDC) there were 16,000 deaths nationwide related to opioid use.
这阿片类药危机，正如现在所谓的，要求采取行动。政策制定者呼吁国家监管机构和保险公司以来，目前没有国家一系列准则，可以帮助监测和指导标准化的处方或使用建议。
目前Medicare报销了许多阿片类药物，并没有建立指导方针或协议。什么是明确的长期阿片类药物用户become increasingly “used to dosages,” and despite the death rates attributed to opioids, these patients can often function on incredibly high daily dosages. Someone new to the drug could be severely compromised or even die if initially prescribed dosages in that range.
State workers’ compensation systems (California, Washington, Utah, Texas) and the Veterans Administration currently use ACOEM, Official Disability Guidelines orODG.（以证据为基础的医疗和返回工作指南），或其自己的指导方针，授权使用阿片类药物来治疗四个痛苦领域。但是，有一个明显的运动，修改和减少处方，剂量和方案持续时间的数量主流医学界定期规定。ACOEM在2014年底发布了最新的指导方针，ACOEM Practice Guidelines: Opioids for Treatment of Acute, Subacute, chronic and Post-Operative Pain.
Every guideline is based on MED or morphine equivalent dose。典型的吗啡当量每日剂量为30毫克吗啡（口服）每次4至6小时，等于每天120-180毫克吗啡“或其等同物”。因此，如果分配的药物是Dilaudid，则给予吗啡当量剂量为7.5mg，每30毫克吗啡，或每日30-45mg的Med。许多治疗方案only red-flag dosesat or beyond an MED of 120 mg. The California Medical Board proposed an upper limit to flag an MED above 80 mg daily in 2014, and ODG guidelines offered the same cutoff. Currently there is consideration by the Division of Workmen’s Compensation (DWC) to lower their guidelines to flag use above an MED of 50 mg daily. Many of the organizations mentioned also want to propose new guidelines for “annual attempts to wean patients off opioids entirely.”
疾病控制中心释放了latest guidelinesfor prescribing opioids for chronic pain in March 2016. It recognizes the role that opioids play in the management of certain cases of pain, but it also recommends certain non-opioid therapies when:
这risks of use outweigh the benefits;
患者想要并愿意做更多的事情，而不仅仅是用药物掩盖疼痛；
When opioids are indeed indicated but use (dose, frequency) should be tapered as quickly as possible;
When pain exceeds 90 days duration.
ACOEM 2014指南反映了对疼痛研究的近264,617篇文章的评论，至少有263项实际研究和157项研究认为高质量或中等质量。对于四种疼痛情况，每一个都有一组全面而周到的准则that attempts to provide pain control but that also aims to avoid drug dependence.它仍然允许医生单独确定是否超过建议的最大每日剂量或更长的治疗阶段。That’s because none of the studies used to generate the 2014 guidelines involved patients with chronic pain (not of cancer origin) on longer term opioid therapy. The one thing this new set of guidelines seems to support, at least by California policymakers, is placing limits on employer payments for long term use of阿片类药物。
If you are someone suffering with severe慢性疼痛，，，，that last statement likely scares you. It shouldn’t. There are a number of therapies that may have the potential to help you to either avoid taking opioids, to limit the time you are on an opioid drug regimen, or to help wean you from opioids. Experts including physiatrists and interventional pain specialists as well as疗法和骨疗法医生可以评估您的疼痛状况并创建一个有助于限制阿片类药物的计划，取代或增强具有非药物治疗的药物的使用。物理疗法is one such option.大约20分钟的运动等于12毫克羟考酮，来自疼痛缓解能力Too often patients don’t understand that their chronic pain is an indicator of tissue damage or tissue sensitivity —他们的“止痛警报”设置得太高了and treating that problem with medications won’t resolve it.
我与南卡罗来纳州Greenville的ATI物理治疗的物理治疗师达到汤姆丹尼斯，DPT，OCS，Faaompt。他对待患者慢性疼痛on a regular basis. Here are some of my questions and the answers he supplied:
描述您看到的不同类型的患者，患有慢性疼痛
“有些人有长期的机械抱怨，例如膝盖困扰，他们通常在传统的PT（加强等）方面做得很好。当我们谈论慢性疼痛，这些通常不是我们正在谈论的患者。Central Sensitivityis a blanket term we talk about when someone has more multi-regional or complex pain (chronic low back pain), chronic neck pain,纤维肌痛，，，，chronic fatigue syndrome，，，，Lyme’s disease, etc.). We also have patients with complex regional pain syndrome where their presentation is very intense and unique.”
您的鸦片中有多少患者（您知道）？
“可以预见，绝大多数。但是我们一次又一次听到的是他们不喜欢副作用，对于许多患者而言[阿片类药物]不有效，尤其是当患者患有更多神经源性症状时（radiculopathy，坐骨神经痛）或多区域疼痛（慢性背部和颈部疼痛，纤维肌痛）或其他复杂疾病（复杂的区域疼痛综合征，莱姆病，慢性疲劳综合征）。很少有人会遇到不在阿片类药物上的复杂痛苦的人。”
丹宁格先生解释说，经常有抵抗物理疗法，尤其是如果它在与另一位从业者的先前接触中失败了。他提出必须相信，从业者和疗法不会以某种方式增加疼痛或伤害他们，而当建立这种情况时，患者通常愿意承诺。他确实承认，让疼痛或脱节的组织会出现不适，但要对练习在一步中，考虑到中央敏感性的逐步方法可以有助于限制这些情况。
他指出，需要评估的主要因素是“个人心理社会痛苦的水平（depression焦虑，创伤后的压力等）在那里拥有培训的心理健康提供者，培训与具有复杂痛苦的人员可以成为关键。它可以归结为患者愿意了解他们痛苦经历的因素及其愿意和能力，使他们的信仰结构和生活变化。“
因此，慢性疼痛患者的团队合作方法可能会很有帮助。丹宁格先生分享说，他“很幸运能与脊柱外科医生，疼痛管理和康复提供者一起工作，在那里我们有一致的交流。当我们第一次开始向患者介绍疼痛神经科学教育和认知行为疗法我们在教育医生方面，就我们正在做的事情以及为什么。鉴于支持这种方法的丰富研究，他们非常支持。“
你能描述一下成功的故事吗？
“一个病人,医院迎宾,遭受chronic neck pain, jaw pain, and headaches, which had persisted for many years. She was about to lose her job due to frequent absences and was forced to go onto FMLA. She had seen multiple PTs and chiropractors who had convinced her something was wrong with her alignment, posture, etc. In truth, she was someone who had a lot going on in her life, was scared of movement and her pain, and had completely lost her independence and locus of control. We took a hands-off approach of care (no manual therapy) because she had become reliant on getting manipulated, so we helped to educate her and systematically introduce strengthening, which proved effective.To this day, I still get emails from her that she is doing great, is gainfully employed, and off all medication. She sticks in my head because she shared afterward that she wasvery close to suicide这次旅程救了她的生活！“
我还通过电子邮件与教授朱莉·马丁（Julie Martin）交谈，后者能够通过物理疗法解决她的疼痛问题，从而使她的疼痛药物治疗方案大大减少。她曾经服用六种治疗方案，非常高剂量，每天减少到一种药物。她向我讲述，她“无法完成诸如卸下洗碗机或去杂货店购物之类的基本日常任务。我是一个非常独立的人，所以必须寻求帮助的帮助对我来说非常令人沮丧。此外，由于痛苦，仅仅在工作中度过一天非常具有挑战性。”
她的手术结局包括肩膀和颈部疼痛，然后随后不舒服背痛。她在几种止痛药中，尝试过类固醇注射，并尝试物理治疗，这并没有导致她希望的结果。重要的是要注意，尽管结果良好和结果不佳，但她的第三次尝试使用物理治疗（她的激励减少她的药物治疗方案非常强烈）取得了成功。朱莉非常清楚，与她的物理治疗相结合，她还有经常按摩，并与私人教练合作。
在探索替代治疗方面，朱莉，朱莉，朱莉，给他人陪伴腰痛的人？
“When you have a problem like背痛这会影响日常生活，我认为重要的是尝试所有可能的选择。我发现，与所有给您照顾的人交流是关键。我的医生是第一次将我转交给治疗师的人，我继续与她签到我的进步。我的治疗师就我在家和私人教练应该做的伸展运动和练习提供了很好的建议。他还帮助我表达了我从massageso I could communicate well with mymassage therapist。I also made adjustments in my daily routine that made a huge difference, like using a standing desk. All these things worked well together, and my physical therapist was the point person for helping me to understand how each thing was contributing to my progress.”
遭受严重和持续性慢性疼痛的人太多的人长时间服用了过度剂量的阿片类药物。更多获取个性化的治疗处方，包括治疗范围需要是标准的“处方”和这些选项需要被保险覆盖。也很明显，当一支专业人士团队一起工作时，非阿片类药物慢性疼痛治疗结果可以是很积极的。如果我们想降低与使用阿片类药物相关的死亡率，并限制对这些药物的依赖，那么患者需要教育并获得替代性非阿片类药物疗法。
Pharmacies are also getting in on the fight against the opioid epidemic.CVS宣布它将将一些阿片类药物限制为7天。
