Jake Magel, PT, PHD, DSc, FAAOMPT
Background
Most patients treated by outpatient physical therapists (PTs) have musculoskeletal pain and 1 in 3 use prescription opioids. About 25% of those with musculoskeletal pain who are prescribed opioids for 90 or more days may have opioid misuse (taking prescription opioids in ways other than prescribed). PTs, Primary Care Providers (PCP), addiction leaders and scholars advocate that PTs should play a greater role in screening and addressing patients with opioid misuse. Unknown are the PCPs attitudes toward PTs’ role, competency, and adequacy in addressing opioid misuse, the PCPs preferences for how PTs should screen and address opioid misuse and the strategies for PTs to communicate with PCPs about patients with suspected opioid misuse. PCPs coordinate and prescribe opioids for patients. Although unknown, PCPs may not favor PTs in identifying and/or addressing opioid misuse among their patients; strategies for how to communicate this condition in a collaborative way may improve communication between PTs and PCPs about opioid misuse.
Our Aims:
Aim 1: Evaluate the attitudes of PCPs toward PTs (e.g., PTs’ adequacy and legitimacy in their role), addressing opioid misuse in outpatient physical therapy practice. We will use surveys and semi-structured interviews to understand PCPs attitudes toward PTs addressing opioid misuse.
Aim 2: Determine the optimal strategies for PTs to work collaboratively with PCPs about patients with suspected opioid misuse. Semi-structured interviews with PCPs will be used to understand the optimal strategies for PTs to work collaboratively with PCPs to address opioid misuse.
Aim 3: Develop a treatment manual for PTs to address and communicate opioid misuse using the results from Aims 1 and 2. We will develop an initial draft of a treatment manual followed by checking the manual with PCPs then finalize the manual. Our results will provide pilot data to test the effectiveness of PTs to address opioid misuse.
Background
Our project will determine PCP preferences for collaboration strategies from PTs and will advance our ongoing program to develop PT-led interventions to address patients with long-term opioid treatment and suspected opioid misuse (S-OM). Our program of research examines, and aims to improve, clinical outcomes by addressing opioid misuse and preventing the transition to OUD and potential overdose. Our work in opioid misuse communication and collaboration will also be applicable to communication and collaboration from PTs to PCPs regarding other vulnerable conditions (e.g., suicidality, physical or mental harms). Our work is grounded in the collaborative care model,21 a systematic approach to effectively manage chronic conditions (e.g., opioid misuse, pain) through integration of PTs and other providers (PCPs).
Our long-term goal is to improve outcomes of patients with opioid misuse and co-occurring musculoskeletal pain who are managed by PTs.
Our objective for this proposal is to understand the optimal means to promote collaboration between PTs and PCPs for patients with opioid misuse.
Our Aims:
Aim 1: Understand the role of the PT from the PCP perspective and preferred collaborative strategies for patients with S-OM. Our mixed-methods approach entails sequential collection and qualitative data analysis to (1) explore PCP perceptions about whether PTs should screen, refer, or counsel patients with S-OM; (2) how PTs should communicate S-OM to a PCP; and (3) understand the next steps a PT should take to address a patient with S-OM using 20 semi-structured interviews, followed by quantitative survey data to confirm these perceptions and strategies in a larger cohort of PCPs.
Aim 2: Evaluate PCP attitudes and beliefs about PTs adequacy and legitimacy in screening, referring, and counselling patients for S-OM. Our approach will survey PCPs using a modified version of the Drug and Drug Problems Perception Questionnaire Role (DDPPQ) Adequacy and Role legitimacy subscales.
Aim 3: Develop a training manual for PTs to work collaboratively with PCPs to manage S-OM among patients. An iterative approach for manual development will include 1) incorporating Aims 1 and 2 results and our research team expertise to develop an initial draft and 2) recruiting PCPs who participated in Aim 1 interviews to review and amend the manual for final draft.
Background
The U.S. Preventive Services Task Force7, stakeholders, and addiction scholars8 and have called for all healthcare providers to be trained to screen, assess, treat or refer patients who engage in drug use. PT leaders, including members of our research team, advocate for physical therapists to play a greater role screening and managing patients with OM.9 As such, our research team conducted a national survey of physical therapists about their readiness to manage patients with orthopaedic conditions and co-occurring OM. More than 89% of respondents agreed that physical therapists can play a role in modifying patterns of opioid use.10 Preliminary results of our ongoing survey of patients seen in PT (n=869) indicates that if a physical therapist suspects OM, 81% of patients agree that the physical therapist should engage the patient in a conversation about OM and 87% of patients agree that it is appropriate for the physical therapist to refer the patient to a specialist to address OM. Leveraging the PT setting to engage patients with OM could mitigate the transition to OUD and prevent opioid-related overdose and death.
Our long-term goal is to improve the management of patients with OM in the PT setting. Developing procedures that physical therapists can easily implement into routine clinical practice for patients who may have OM is a critical first step.
The purpose of this study is to develop and operationalize key procedures for physical therapists (n = 12) to address patients who are at risk for or have OM. We will train physical therapists in procedures to:
1) Engage patients at risk for OM in conversations about appropriate opioid use
2) Screen
3) Assess these patients for OM
4) Refer patients for further treatment if OM is suspected
Our Aims:
1. Qualitatively evaluate physical therapists' perceptions and recommendations for implementing OM procedures. Our approach will be to conduct 1 focus group composed of the physical therapists who attended the training after presenting each session for a total of 2 focus groups (i.e., 1 focus group each for engaging patients in conversations about opioid use, screening and assessing patients for OM and referring patients for further treatment of OM) to evaluate the physical therapists’ receptivity to the procedures. During these focus groups, a modified Delphi methodology will be used to arrive at final operationalized procedures, which will be manualized.
2. Evaluate the implementation of the manualized OM procedures. We will use the RE-AIM framework to guide our evaluation of Aim 2. Our approach will be to use mixed-methods to quantitatively assess key implementation measures including but not limited to the proportion of physical therapists that agreed to attend the training that completed the training, OM knowledge and attitudes test scores pre- and post-training testing, the number physical therapist who screened, assessed and referred a patient with OM for further treatment. Next, semi-structured interviews will be used to provide context to our quantitative results and to assess barriers and facilitators to the implementation of the OM procedures.