It is seldom helpful to overstate a problem. Incendiary language about challenges does not often lead to workable solutions. But the current threat we face regarding deadly consequences of the use, misuse, and addiction to opioids merits a certain level of anxiety. After all, more people died from drug overdoses in 2017 than by gun violence or car accidents. Thus, the term opioid crisis is appropriately alarmist.
Here, we will look at the history of opioid use in this country. We will consider current terminology about the topic of addiction, and we will review some of the strategies being considered and implemented to try to reverse some of the dangerous trends of recent years.
In this setting, it is not possible to provide a comprehensive overview of this complicated and emotionally fraught topic. Rather, I will focus on certain aspects that seem most relevant for massage therapists, with an emphasis on where our work fits and the opportunities that currently exist for our profession to be helpful.
Addiction, a.k.a. Substance Use Disorder
The term addiction is complicated. Does it apply to legal substances as well as illegal ones? Is there a difference between prescription drugs and “street” drugs? What about non-drugs: can a person become addicted to caffeine or sugar? If yes, does this follow the same rules as an addiction to oxycodone, and can it be discussed in the same way?
For the purposes of this article, we will refer to the National Institute of Drug Abuse (NIDA) definitions regarding addiction and related topics. Interestingly, “addiction” does not appear in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5). NIDA has adopted the DSM language—substance use disorder—to describe the situation when a person becomes dependent on a substance for various reasons.
Substance use disorder, according to NIDA, is compulsive drug seeking, despite the knowledge and experience of negative consequences. This can occur on a spectrum of severity, from mild to moderate to severe (see Mild, Moderate, or Severe Substance Use Disorder, right).
Drug misuse refers to using drugs in unhealthy ways, or in ways not intended—that is, in overly large doses, or use by someone other than the patient. The term abuse is now avoided by NIDA—even though it’s in the acronym—because it is seen as stigmatizing and may deter people from seeking appropriate care.
The situation we have traditionally called addiction, with increasing tolerance and a need to avoid withdrawal symptoms, is the most severe form of substance use disorder. At this stage, we can expect to see substantial changes in the brain, especially in relation to inhibitions and reward center functions.
History of Opium Use in the United States
Opium has been harvested for human consumption since at least 3400 BCE, but its widespread use didn’t become prevalent until the 1800s—largely thanks to the British East India Tea Company (but that’s a story for another time). The immigration of Chinese laborers to North America to work on the railroads brought the habit of opium smoking to this continent, and it gained popularity in medical settings as a potent pain reliever during the Civil War.
In the early 20th century, opium-based substances, including morphine, cocaine, and heroin, were legal to use without prescription, although they were often heavily taxed. Then, in 1909, “smoking opium” was banned; this was the first US law banning the use of a substance for non-medical use. In 1914, all use of opium-related substances was banned, except as directed by physicians. Over the next 75 years or so, guidelines for medical professionals to dispense opioids became increasingly restricted.
The downside was serious. People with chronic pain were described as malingerers, deluded, and unworthy of treatment. Pain management was ineffectual, and millions of people with chronic pain had little recourse. Only people dying of cancer were given this pain-relieving intervention.
In the early 1990s, the problem of pain management finally began to gain some traction. Physicians were eager to find workable interventions, and a couple of small-scale retrospective observational studies suggested that, in certain very limited circumstances, opioids could be used for intractable pain with little risk of addiction. This led to a loosening of the guidelines for opioid prescriptions, heavy marketing from pharmaceutical companies, and recommendations from many policy-making bodies to treat pain more fully. It helped that oxycodone, a morphine-like drug that can be mixed with non-narcotic pain relievers, was being aggressively (and deceptively) marketed as a low-risk pain reliever.
By 2012, doctors in the United States were issuing 282 million prescriptions for opioid pain relievers each year—that’s more than one prescription for every adult in the country. At the same time, the number of deaths related to opioid overdose was rapidly climbing. This was the height of opioid prescription writing; but in 2016, (the latest year we have data for) there were still 236 million prescriptions issued.
In 2017, 72,000 Americans died from drug overdoses, including prescription and illicit drugs. This represents a twofold increase over the past 10 years.
Mild, Moderate, or Severe Substance Use Disorder
The following is a condensed version of the DSM-5 criteria for mild, moderate, and severe substance use disorder. While some variances exist for specific substances, the basic pattern is that having 2–3 of these symptoms meets the criteria for mild substance use disorder; 4–5 symptoms form the criteria for moderate substance use disorder; and 6 or more define severe substance use disorder.
• The substance is taken in larger amounts and/or over a longer period of time than intended.
• The person cannot voluntarily control use.
• The person invests a lot of time in accessing, using, and recovering from use of the substance.
• The person has a persistent craving for the substance.
• Recurrent use leads to a failure to fulfill obligations at work, school, or home.
• Use of the substance persists, despite negative consequences.
• The person gives up on, or reduces, important activities because of use.
• The person uses the substance even in situations that are potentially hazardous.
• The person continues use, despite knowledge of physical and psychological problems.
• The person develops increasing tolerance: they need more of the substance to achieve the desired sensation, or the same dose results in diminished effect.
• The person develops withdrawal symptoms when use is suspended, and they may use the substance to avoid withdrawal symptoms.
We’ve been trying to put the brakes on opioid use in the US, but it is a complicated problem. One of the consequences of cutting back on opioid drug prescriptions without offering viable alternatives is that patients may turn to street drugs—heroin and fentanyl—as cheaper and more accessible options. About three-quarters of all new heroin users begin as users of prescription pain medication.
Strategies to Manage Opioid Misuse
All this dire information cries out for a concerted public health effort to find a way to provide access to pain-relieving options while curbing opioid use and decreasing opioid-related deaths. The vast majority of people with substance use disorder don’t receive effective treatment. We see that people who are addicted to opioids have the best outcomes with appropriate pharmacological support, along with support groups, community-led prevention strategies, and initiatives that lift the “drug abuser” stigma for improved access and use of services.
In 2017, the US Department of Health and Human Services (HHS) declared the opioid crisis a public health emergency and issued a five-point strategy to combat the problem. These include improving access to treatment and recovery services for people with opioid use disorder; promoting the use of overdose-reversing drugs; improving surveillance of public health to better understand the scope of the problem; supporting research into pain and addiction; and advancing better practices for pain management.
The Joint Commission is a not-for-profit organization that certifies and accredits many health-care organizations. In 2018, it published a statement calling for evidence-based, non-pharmacological treatments for pain management, and massage therapy is specifically listed among those interventional options. The Joint Commission also recommends that pain specialists address psychosocial risk factors for pain and substance use disorder, with realistic goals and multidisciplinary approaches to treatment. They are especially interested in outcomes that lead to improved physical function. This is relevant for us, because functional goals are often well supported in massage therapy research.
The American Society of Interventional Pain Physicians (ASIPP) has also weighed in with a three-tiered approach to the opioid crisis. They suggest more aggressive public education regarding the dangers of illicit drug use—specifically for heroin and fentanyl; improved access to non-opioid therapies (including physical therapy and other interventions); and improved access to overdose-preventing drugs. ASIPP also notes dysfunctional incentives for opioid prescriptions in current government policies that they argue make the problem worse rather than better.
I hope you can see some common themes here. The HHS, the Joint Commission, the ASIPP, and many other policy-making bodies have identified that opioid addiction is a problem, that people in pain deserve treatment, and that we need to find better ways to meet these needs. This represents a big opportunity for massage therapists.
Opportunities for Massage Therapists: How Can We Help?
The observation that rubbing the skin can help with pain dates back to the first human who ever compassionately stroked another person’s sore body. But having policy-makers understand that skilled massage therapy could be effectively integrated into a multidisciplinary approach to chronic pain management is relatively new. The guidelines now being promoted by the HHS, the Joint Commission, the ASIPP, and others make room for manual therapies in ways we haven’t seen before. This provides some unprecedented opportunities, if the profession is ready to step up to them.
How do we move forward in this direction? If we want to help the millions of people who struggle with difficult-to-treat pain, and if we want the massage therapy profession to be considered a partner in that effort, we have some hard work to do. However, the word partner in this context is not truly applicable. Until our profession has a higher education infrastructure so people can seek out graduate and advanced degrees in massage therapy, we cannot call ourselves partners with other degreed health-care providers. That said, we have the access, time, and expertise to offer practical help to people with chronic pain that the rest of their health-care team may lack. With that in mind, here are some steps each person can take to help us all rise to the challenge at hand:
Know the research. The position papers on pain management rely on published, credible, and accessible research findings. I am personally proud to see that among the studies frequently cited are the three systematic reviews and meta-analyses commissioned by the Massage Therapy Foundation (MTF) that looked at massage therapy, pain, and function in general populations, in surgery patients, and in people with cancer. These articles are included in the reference list for this piece. Articles from the International Journal of Therapeutic Massage & Bodywork, the MTF’s academic peer-reviewed, open-sourced journal, are also frequently cited. Massage therapy research is being used to influence public health policy. Get familiar with it, so you can use it too.
Be educated about pain and pain research. The research on pain and how to manage it has revealed some important discoveries. The chances are good that what you were taught in massage school is no longer considered accurate, and the differences may influence how you work with clients who live in pain. Seek out current information on pain in the context of manual therapies. You may be surprised.
Work with pain management specialists.
If working with clients who have pain—especially chronic pain—is your passion, then this is a great time to build relationships with pain management specialists. Do you live in a place with hospitals or pain management facilities? Take your knowledge, the research, and the recommendations of policy-makers to craft some messages that could create opportunities for you to work in those settings.
Pay attention to legislative activity. Keep an eye on what is happening in your area regarding your license and scope of practice. If the massage laws in your area don’t reflect the research and policy recommendations from the government, communicate with your legislators to raise awareness of the power of your work.
This article barely scratches the surface of what the opioid crisis means to our country and our loved ones. There is so much more to say about the human cost of this problem and the ways massage therapy might be able to help. Clients who live with pain need our skills. They need us to be well informed, highly educated, and willing to be part of an integrated health-care team. Are you ready to rise to that challenge?
Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology, (available at BooksofDiscovery.com), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.
Resources
“A History of Opiate Laws in the United States.” Accessed January 2019. www.naabt.org/laws.cfm.
“Declaration of Montréal—IASP.” Accessed January 2019. www.iasp-pain.org/DeclarationofMontreal.
Durkin, Erin. “US Drug Overdose Deaths Rose to Record 72,000 Last Year, Data Reveals.” The Guardian. August 16, 2018. www.theguardian.com/us-news/2018/aug/16/us-drug-overdose-deaths-opioids-fentanyl-cdc.
Jones, Mark R. et al. “A Brief History of the Opioid Epidemic and Strategies for Pain Medicine.” Pain and Therapy 7, no. 1 (June 2018): 13–21. https://doi.org/10.1007/s40122-018-0097-6.
National Institute on Drug Abuse. “Opioid Overdose Crisis.” Last updated March 6, 2018. Accessed January 2019. www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis.
“Overdose Death Rates.” Last updated August 9, 2018. Accessed January 2019.
www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
“The Impact of Massage Therapy on Function in Pain Populations—A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part I, Patients Experiencing Pain in the General Population.” Pain Medicine 17, no. 7 (July 2016). Accessed January 2019.
https://academic.oup.com/painmedicine/article/17/7/1353/2223191.
“The Impact of Massage Therapy on Function in Pain Populations—A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part II, Cancer Pain Populations.” Pain Medicine 17, no. 8 (August 2016). Accessed January 2019. https://academic.oup.com/painmedicine/article/17/8/1553/2223186.
“The Impact of Massage Therapy on Function in Pain Populations—A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part III, Surgical Pain Populations.” Pain Medicine 17, no. 9 (September 2016). Accessed January 2019. https://academic.oup.com/painmedicine/article/17/9/1757/2399356.
The Joint Commission. “New Joint Commission Advisory on Non-Pharmacologic and Non-Opioid Solutions for Pain Management.” August 28, 2018. Accessed January 2019.
www.jointcommission.org/new_joint_commission_advisory_on_non-pharmacologic_and_non-opioid_solutions_for_pain_management.
“The Science of Drug Use and Addiction: The Basics.” Accessed January 2019.
www.drugabuse.gov/publications/media-guide/science-drug-use-addiction-basics.
Tick, Heather et al. “Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper.” EXPLORE 14, no. 3 (May 1, 2018): 177–211. https://doi.org/10.1016/j.explore.2018.02.001.