Avoidable Opioid Misuse: Treating Mechanical Pain With a Chemical "Solution"

Imagine adding STP to a poorly performing engine due to a bad carburetor. 

That's the analogy that Chad Gray, who is the CEO of Integrated Musculoskeletal Care (IMC), uses to describe an all-too-common approach to musculoskeletal (MSK) issues.

[For a deeper perspective on Gray's organization, Brian Klepper (one of the foremost experts in high performance benefits) outlined the deep well of success and experience that IMC has demonstrated in the following piece on healthcare value:]

Since a major on-ramp to non-evidenced based use of opioids is improper prescribing for MSK-related pain, I asked Gray to expand on his analogy. As a non-clinician, I found this description to be useful. Do you agree with this analogy? I particularly look forward to those who have evidence that is at odds with this analogy. Here's how Gray explained it:

No physician wants to create an addicted patient. In almost all cases they simply want to mitigate their pain. Good intentions with a bad strategy. The breakdown in the system stems from a poor understanding of pain and how to diagnose and classify it correctly. In effect you have to match the treatment to the patients condition which means you need to possess a reliable method of diagnosing pain. Human beings experience three types of pain.

1. Thermal pain - quite rare and only produced in the very ill and systemically sick patients,
2. Chemical or inflammatory pain - pain that is mediated through a release of chemicals at a site of injury. This pain is short lived ( 5-7 days), occurs when trauma happens and is only present in 2-5 % of all patients in pain.
3. Mechanical pain- pain that is mediated through/by distortion or pressure on tissue(90+% of all pain humans experience). Bend your finger back as far as you can until pain is produced and you have just experienced mechanical pain in its purest form. A bulging or herniated disc in 95% of all patients produces pain because the wall of the disc is being distorted or strained just like your finger was when it was hurting.

You can't treat mechanical pain with a chemical intervention ( pills and injections). You can't treat chemical pain with a mechanical intervention. Makes sense right! Problem is we have a system built around using chemicals to manage pain and providers who receive less than 2 weeks of education in medical school around how to adequately assess and diagnose patients in this space. The evidence to this is overwhelming There are dozens of studies that show little influence on back or joint related pain (less than 1 point on a 10 point pain scale , and that's in only 30 % of the cohort ) when using opioids, analgesics, muscle relaxants and steroids yet every PCP and specialist in the land has this as the first stop off for MSK patients. When the simple analgesics and muscle relaxants don't work then escalate to opioids. Numerous studies show that less than 5% of patients experience any change in back pain when epidural steroids or transformational injections are used to put the medicine at the supposed source of symptom. Why are these studies struggling to find treatment effect on patients in pain with some of the most well trained examiner/physicians in the world conducting the study? It's simple, we don't train them to assess patients in a reliable way and to match chemical patients with chemical interventions and match mechanical patients with mechanical interventions ( surgery and movement based strategies). 

90% of opioids are prescribed for back or chronic joint pain. The solution to the crisis is to teach providers to reliably sub-group patients into their appropriate pain group. Mechanical patients only get mechanical solutions and chemically dominant or inflammatory patients get chemical treatment. Our failure to do this has allowed us to continue to use treatment methods long ago determined to be ineffective in this population and also forces providers to become inventive. We blame the patient, we claim they are gaming the system, we think it's psycho-somatic or a construct in their mind when in reality we are not applying the right treatment to the right patient to the right body part at the right time. 

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Dave Chase is the co-founder of the Health Rosetta (a LEED-like organization for healthcare), and author of the book, “The Opioid Crisis Wake-up Call: Health Care is Stealing the American Dream. Here's How We Take it Back.” Follow the link to the book for a free download of the book. Chase's TEDx talk was entitled "Healthcare stole the American Dream -- here's how we take it back." See the Health Rosetta website for how to get involved, resources and how to join others to support its mission.

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