Opioids are commonly prescribed for acute and chronic pain, including after surgeries such as THR, TKR, and ORIF. Opioids have numerous side effects and a high potential for misuse. Over-reliance on opioids for acute and chronic pain management has led to alarming trends across the United States, including a record number of people developing opioid use disorders, overdosing on opioids, and dying from overdoses. From 2015 to 2017, the annual number of opioid-related deaths rose 44% from 33,000 to 47,600.¹

Many Medicare and Medicaid beneficiaries and their families have experienced opioid use disorder, commonly referred to as addiction. Given the growing body of evidence on the risks of opioid misuse, CMS outlined their strategy with four priority areas. The fourth priority is directly related to physical and occupational therapy services: Increase the use of evidence-based practices for acute and chronic pain management.²

Biophysical Agents offer evidence-based treatment alternatives to decrease acute and chronic pain and can be used to replace or wean an individual from narcotics.

• TENS could significantly reduce pain and opioid consumption after total knee arthroplasty with fewer adverse effects.³
  
• Treatment of chronic low back pain with TENS demonstrated significant pain reduction and may lead to less pain medication usage.⁴
  
• Low-Frequency TENS does not produce analgesia in opioid tolerant people, but High-Frequency TENS does.⁵

ACP’s Evidence-based Pain Management clinical treatment pathway assists the clinician in determining which biophysical agent and the most optimal parameters based on pain presentation.⁶

Taking opioid analgesics can impact the effectiveness of biophysical agent treatments. Key factors to consider when an individual is taking opioid analgesics:

• Treat the patient as medication is wearing off.
  
• Use IR, US, SWD, and Sensory or Nerve Block electrical stimulation when the patient is on narcotics. Motor stimulation may not give any added pain relief due to the pain medication filling the same receptor site (Mu).
  
• Use Motor-Sequential stimulation to replace narcotics and restart the endorphin system.
  
• Narcotics should be PRN and titrated as biophysical agents manage the pain.
  
• Attempt to reduce analgesics to a single type if possible.

References:
1. CDC.gov
2. CMS.gov. Centers For Medicare & Medicaid Services (CMS) Opioid Misuse Strategy 2016, January 2017
3. Li J, Song Y. Transcutaneous electrical nerve stimulation for postoperative pain control after total knee arthroplasty: A meta-analysis of randomized controlled trials. Medicine 96:37, 2017
4. Jauregui JJ, Cherian JJ, Gwam CU, Chughtai M, Mistry JB, Elmallah RK, Harwin SF, Bhave A, Mont MA. A Meta-Analysis of Transcutaneous Electrical Nerve Stimulation for Chronic Low Back Pain. Surch Technol Int. 28:296-302, 2016
5. Vance CG, Daily DL, Rakel BA, Sluka Ka. Using TENS for pain control: the state of the evidence. Pain Manag. 4(3):197-209, 2014
6. ACP’s General Pain Management Treatment Pathway Acute vs. Chronic Pain, MRK 0455