By: Katie Hunter
It should be a surprise to no one that we are in the middle of a serious, nationwide opioid epidemic. And to top that off, a crisis on opioid overdose. Did you know that on average 115 Americans die each day from opioid overdose?2 In October 2017, President Trump declared the opioid crisis a public health emergency and has since been developing strategies to combat this crisis.1 It was just a week ago that the New York Times published a story on an opioid epidemic that has been ongoing for over 150 years in the United States. Unfortunately, the rise of opioid use and overdose has been drawn back to the prescription pad; especially when you consider that there has been no change in the amount of pain reported by Americans since 1999 while the amount of opioids being prescribed has quadrupled.3
As a pelvic health physical therapist, I am all too familiar with the great lengths to which people will go for relief from chronic pain. As I continue to evaluate and treat patients who have been suffering with undiagnosed pain for over 10 years and I see opioids in their medical history, it brings me to ask the following questions:
Are opioids an appropriate treatment for pelvic pain?
What can I do to help fight the opioid epidemic?
To answer my first question…
There is no research to definitively support or negate opioids as a treatment for pelvic pain. This is an ongoing debate in the medical community, particularly when it comes to opioids and chronic, neuropathic pain. Opioids have been shown to effectively provide short-term relief for acute pain; however, the evidence is limited in its benefits for chronic pain. This leaves us to consider the individual, risks, benefits, and our clinical expertise.
In the Urological and Gynaecological Chronic Pelvic Pain textbook, Dr. Robert M. Moldwin, MD reports that opioids can effectively treat chronic pelvic pain in the short-term by altering pain perception through afferent pathways of the central nervous system.4 NMDA-antagonizing opioids have been shown to lower nerve hyperexcitability, which is useful considering that persistent, neuropathic pain involving the pudendal nerves can lead to hyperexcitability in the nociceptors. However, opioids do not affect neuronal firing or transduction, which partially explains the temporary nature of opioid efficacy and will not address the neuroproliferative component of chronic, neuropathic pain.
In short, they can help reduce the pain intensity and give short-term relief but not effectively treat pain long-term. Opioids are best utilized with other therapies. The authors make a point to discourage monotherapy treatment with opioids and rather use adjunct therapist in combination with opioid prescriptions.
Opioids for chronic pelvic pain come with some pretty heavy risks like tolerance, dependence, and depression;5 side effects we see time and time again in the clinic. However, some of the other side effects gravely affect patients with pelvic pain. For one, these medications cause constipation, which is typically a known cause and effect of pelvic floor dysfunction, and pelvic pain (read more about this here). This can lead to more dysfunction and more pain. Opioids also cause decreased androgen production,4 leading to reduced levels of estrogen and testosterone which are risk factors for vestibulodynia, erectile dysfunction, and depression. Testosterone also helps our body tolerate and manage pain,5 which can lead to the downward spiral of more intense pelvic pain. Lastly, increased sensitivity to pain is listed as a side effect. Why would we recommend a medication that causes more pain and sensitivity in an area that is already so painful and sensitive?
If you weigh the risks and benefits, opioids are not an appropriate medication for pelvic pain when you consider that most pelvic pain is chronic (lasting >12 weeks). The CDC advises nonopioid therapy for chronic pain outside of active cancer, palliative, and end-of-life care.7 We have a whole laundry list of treatments that have evidence to support their efficacy of treating chronic pelvic pain that does not include opioids. These include:6
- Nerve blocks
- Physical therapy
- Dry needling
- Trigger point injections
- Cognitive behavioral therapy
- Behavioral modifications
- Diet modifications
So, what can I do to help this epidemic?
The best thing I can do is stay information on this topic and share my ever-growing knowledge with my patients in the clinic.
Since we know this epidemic is being perpetuated by prescriptions, I turn to the CDC’s Guidelines for Prescribing Opioids for Chronic Pain7. Here are a few highlights from the guidelines:
- Opioids are not first-line or routine therapy for chronic pain
- Establish and measure goals: the goal is to improve function not just pain
- The clinician should discuss risks, benefits, and role of the patient and provider
- Prescribe the lowest effective dose of immediate-release opioids
- Long-term use is discouraged; opioids are rarely needed longer than seven days for acute pain
- Clinicians should avoid prescribing pain medication and benzodiazepines concurrently
The U.S. Department of Health and Human Services has a 5-point strategy to combat the opioid crisis.8
As physical therapists, we can assist in better prevention of addiction and better pain management. We spend ample time to get to know our patients, understand their lifestyle, their limitations, and their goals. Inquiring about medications on the evaluation is key to recognizing opioid use. Communicating with their primary care physicians and healthcare team can reduce risk for abuse and overdose. Educating the community about more effective and appropriate treatments for chronic pain can reduce the risks associated with this epidemic. Even if we do not hold the prescription pad, we can still be a key player in the fight against opioids.
Patient and Provider Resources:
- The United States Government. The White House (2018, May 24). The opioid crisis. The United States Government. Retrieved from http://www.whitehouse.gov/opioids/.
- Center for Disease Control and Prevention (2017, Aug 30). Opioid overdose. Retrieved from http://www.cdc.gov/drugoverdose/epidemic/index.html.
- Center for Disease Control and Prevention (2017, Aug 30). Understanding the epidemic. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html
- Moldwin, R. (2017). Urological and gynaecological chronic pelvic pain : current therapies. Cham, Switzerland: Springer.
- White, D.H., Robinson, T.D. (2015). A novel use for testosterone to treat central sensitization of chronic pain in fibromyalgia patients. International Immunopharmacology, 27, 244-248.
- Prendergast, S. & Rummer, E. (2016). Pelvic pain explained : what everyone needs to know. Lanham: Rowman & Littlefield.
- Center for Disease Control and Prevention (2017, Aug 29). Factsheet CDC guideline for opioid prescription for chronic pain. Retrieved from
- U.S. Department of Health and Human Services (2018, May 24). Help, resources and information: national opioids crisis. Retrieved from https://www.hhs.gov/opioids/.
- Center for Disease Control and Prevention (2017, Aug 29). Prescription opioids. Retrieved from https://www.cdc.gov/drugoverdose/opioids/prescribed.html.