Patients Perceptions of Physical Therapists Addressing Opioid Misuse

Abstract

Introduction:

In the US, rising numbers of patients who misuse illicit or prescribed opioids provides opportunities for physical therapists (PTs) to be engaged in their care. Prior to this engagement, it is necessary to understand the perceptions of patients who access physical therapy services about their PTs playing such a role. This project examined patients’ perceptions of PTs addressing opioid misuse.

Methods:

We surveyed patients, newly encountering outpatient physical therapy services in a large University-based healthcare setting, via anonymous, web-based survey. Within the survey, questions were rated on a Likert scale (1 = completely disagree to 7 = completely agree) and we evaluated responses of patients who were prescribed opioids versus those who were not.

Results:

Among 839 respondents, the highest mean score was 6.2 (SD=1.5) for “It is OK for physical therapists to refer their patients with prescription opioid misuse to a specialist to address the opioid misuse.” The lowest mean score was 5.6 (SD = 1.9) for “It is OK for physical therapists to ask their patient why they are misusing prescription opioids.” Compared to those with no prescription opioid exposure while attending physical therapy, patients with prescription opioid exposure had lower agreement that it was OK for the physical therapist to refer their patients with opioid misuse to a specialist (β =−0.33, 95% CI=−0.63 to −0.03).

Conclusions:

Patients attending outpatient physical therapy seem to support PTs addressing opioid misuse and there are differences in support based on whether the patients had exposure to opioids.

INTRODUCTION

Over 61% of outpatient physical therapy practice is comprised of patients with musculoskeletal pain,¹ and about 16% of physician visits for musculoskeletal pain are associated with referral to physical therapists (PTs).² In the US, over 2 million adults are annually referred to physical therapy just for low back pain and knee osteoarthritis.^3,4 About 1 in 3 patients treated for musculoskeletal pain by PTs in outpatient clinics take prescription opioids.^5,6 Nearly 25% of patients with musculoskeletal pain who are prescribed opioids for 90 or more days may have opioid misuse (taking prescription opioids in ways other than prescribed).⁷

The US Preventive Services Task Force has called for all healthcare providers to be trained to screen and address (treat or refer to treatment) opioid misuse among patients.⁸ PTs, primary care providers (PCPs), addiction treatment leaders and scholars advocate that PTs should play a greater role screening and addressing patients with opioid misuse.^9,10 Indeed, in our prior work, we found that more than 89% physical therapists agree that they should play a role in managing patients with opioid misuse.¹¹ In the American Physical Therapy Association’s Standards of Practice for Physical Therapy, the functions of the physical therapist examination include identifying both physical therapy needs and other health needs of the patient or client.¹⁸ Physical therapy best practice includes a review of the patient’s medications, which includes the use of opioid medications¹² and leaders in physical therapy recommend that PTs monitor the patient’s dose of prescription opioids for signs of opioid misuse.⁹

While PTs are well-positioned to address opioid misuse and seemingly are willing to do it, what remains unknown are the perceptions of patients regarding PTs’ role in addressing opioid misuse. Patients may not appreciate or want PTs — providers not typically engaged in opioid risk assessment and mitigation — to address this potentially sensitive subject. Furthermore, if patients do not perceive that it is the role of the PT, then it may be difficult for PTs to engage these patients in strategies to address opioid misuse. Finally, it is also unknown whether these perceptions differ based on whether the patient is taking a prescription opioid while attending physical therapy compared to having no history of taking a prescription opioid for pain while attending physical therapy. If there is no difference in these perceptions, then PTs may feel broadly empowered to engage patients in conversations about their potential opioid misuse.

With these knowledge gaps in mind, we conducted a brief, cross sectional, anonymous survey of patients who attended an initial evaluation by a PT to explore their perceptions of PTs addressing opioid misuse. Additionally, we sought to compare these perceptions between patients who were prescribed an opioid while attending physical therapy and patients with no such prescription.

METHODS

Study Design and Survey Construction

Using a cross-sectional study design, a modified instrument¹³ was used to survey all patients who attended a new evaluation for an orthopedic condition at one of 8 outpatient physical therapy clinics within University of Utah Health (UUH). UUH has 8 separate outpatient physical therapy clinics that employ approximately 60 physical therapists who manage over 15,000 new patients each year with musculoskeletal diagnoses. In the survey, opioid misuse was defined as: using prescription opioid medications without a prescription (i.e., the patient is using an old prescription or taking prescription opioid medications prescribed to someone else), or using prescription opioids for a reason other than the condition for which they were prescribed, or using prescription opioids at higher doses, more often, or for a longer period than prescribed.¹⁴ The survey included: (1) patient demographics, (2) questions to determine whether the patient has a history of taking prescription opioids for pain while attending physical therapy and, (3) questions to determine the patients’ perceptions of PTs addressing opioid misuse in their patients. The initial development team reviewed and pilot-tested the survey among themselves for clarity and survey functionality. During pilot testing, the survey took approximately 4 minutes to complete. The Checklist for Improving the Quality of Web Surveys was used in reporting the development, distribution and results of the survey.¹⁵

Survey Distribution

Eligible recipients were all patients who attended an initial visit with a physical therapist for new episode of care in UUH outpatient physical therapy. Using the patient’s email located in the electronic data warehouse, we sent the web-based questionnaire via the Electronic Data Capture System (REDCap).¹⁶ Interested respondents clicked on an electronic link connecting them to the survey. Responses were collected over a 12-week period beginning 12/6/2021 and ending on 2/26/2022. Following the initial survey invitation, up to 3 reminders were sent. The University of Utah’s Institutional Review Board administratively reviewed this project and determined that it is exempted from formal IRB review.

Outcome Variables

Our outcomes were the patients’ level of agreement for each of 8 questions related to PTs addressing opioid misuse with their patients and the agreement with a single question asking whether the patient would answer questions about opioid misuse truthfully. These questions were adapted from a survey developed to improve health care providers’ management of patients with alcohol problems.^13,17 For example, a question related to the frequency with which a health care provider discussed/advised patients about alcohol problems was: “How often do you discuss/advise patients about alcohol problems?”¹⁷ This question was modified into a statement: “It is OK for physical therapists to discuss/advise their patients about opioid misuse?” Table 1 contains the opioid-related items on the survey. The patient’s agreement with each statement in was measured using a 7-point Likert scale (1 = Completely Disagree; 7 = Completely Agree).

Table 1.

Respondent Characteristics

Characteristics	All Respondents n = 839	Currently taking prescription opioid medication or have taken them in the past for pain while attending physical therapy n = 117	Have not taken prescription opioids for pain n = 722
Mean age, y (SD)	53.0 (17.6)	53.7 (17.8)	56.7 (15.9)
Sex (Female)	538 (64.9%)	82 (70.0%)	456 (64.0%)
Race and Ethnicity
American Indian or Alaska Native	9 (1.1%)	3 (2.6%)	6 (0.8%)
Asian	37 (4.4%)	4 (3.4%)	33 (4.6%)
Black or African American	14 (1.7%)	2 (1.7%)	12 (1.75)
Hawaiian or Other Pacific Islander	8 (1.0%)	1 (0.9%	7 (1.0%)
White	748 (89.2%)	105 (89.7%)	643 (89.1%)
Hispanic or Latino	52 (6.2%)	4 (3.4%)	48 (6.7%)
Other	5 (0.6%)	0 (0.0%)	5 (0.7%)

Independent Variables

Our independent variable of interest was whether the patient had exposure to an opioid for pain while attending physical therapy and was dichotomized (currently taking an opioid for pain for the same reason as currently attending physical therapy or had taken an opioid in the past for the same reason as they attended physical therapy in the past versus no history of taking an opioid for pain while attending physical therapy).

Additional variables collected were age, sex, and race/ethnicity. These additional variables were explored for their potential influence on the patients’ perceptions of PTs addressing opioid misuse. Age was a continuous variable, sex was dichotomized into male or female and race and ethnicity were categorical variables.

Data Analysis

Descriptive statistics were used to characterize the sample. Due to the large proportion of patients identifying as White and the smaller proportion of participants identifying as other races, for the regression analyses we dichotomized race into White versus other races. Separate linear regression models were constructed to examine the association between opioid use status (No current or past use of prescription opioids while attending versus current or past use of prescription opioids while attending) and each opioid misuse-related item while controlling for age, sex, race and ethnicity. Influential observations were assessed using Cooks d.¹⁸ All analyses used a 2-sided alpha of .05 and, no adjustments were made for multiple comparisons. Statistical analyses were conducted using Stata statistical software version 17.¹⁹

RESULTS

A total of 3,746 email invitations were sent with 869 (23.2%) responses recorded and 839 (22.4% of email invitations and 97.0% of responses recorded) were included in the final analysis. The reasons for exclusion are included in the Figure.

Figure.

Reasons for exclusion from analysis

The respondents’ demographics are presented in Table 1 by opioid use status. The mean age of the respondents was 53.0 (SD = 17.6) years with 538 (64.9%) females. There were 117 (14.0%) respondents who were currently taking prescription opioids for pain while attending physical therapy or they had taken prescription opioids in the past while attending physical therapy. Overall, the patient perception scores supported the role of PTs in addressing opioid misuse. The highest mean score among all patient perception questions was 6.2 (SD=1.5) for “It is OK for physical therapists to refer their patients with prescription opioid misuse to a specialist to address the OM.” The lowest mean score was 5.6 (SD = 1.9) for “It is OK for physical therapists to ask their patient why they are misusing prescription opioids” (Table 2). Each regression model was run with and without the influential observations removed (based on Cooks d). Our primary predictor (opioid use) did not change to or from being significant with alpha set at .05. Therefore, the results displayed are for the models without influential observations removed. After controlling for age, sex, race and ethnicity, compared to patients who had never taken prescription opioids for pain while attending physical therapy, those patients with exposure to opioids while attending physical therapy had lower agreement that “It is OK for the physical therapist to refer their patients with opioid misuse to a specialist to address the opioid misuse” (β = −0.33, 95% CI = −0.63 to −0.03, p = .03), indicating that patients with exposure to a prescription opioid while attending physical therapy viewed being referred for opioid misuse less favorably than those with no exposure to a prescription opioid while attending physical therapy (Table 3).

Table 2.

Results of Opioid Misuse-Related Survey Items

Characteristics	All Respondents n = 839	Currently taking prescription opioid medication or have taken them in the past for pain while attending physical therapy n = 117	Have not taken prescription opioids for pain n = 722
1. It is OK for physical therapists to ask their patients questions to find out if they have misused prescription opioid medication in the past	5.8 (1.7)	5.7 (1.8)	5.8 (1.7)
2. It is OK for physical therapists to ask their patients questions about whether they are currently misusing prescription opioid medications	5.9 (1.6)	5.8 (1.7)	6.0 (1.6)
3. It is OK for physical therapists to use questionnaires to determine if their patients are misusing prescription opioid medication.	6.0 (1.6)	5.7 (1.7)	5.9 (1.6)
4. It is OK for physical therapists to ask their patient why they are misusing prescription opioids.	5.6 (1.9)	5.3 (2.0)	5.9 (1.9)
5. It is OK for physical therapists to ask their patients about the frequency of their prescription opioid medication misuse.	5.8 (1.7)	5.5 (1.8)	5.9 (1.7)
6. It is OK for physical therapists to assess their patients’ readiness to change their prescription opioid misuse behaviors.	5.7 (1.8)	5.4 (1.9)	5.7 (1.8)
7. It is OK for physical therapists to discuss/advise their patients to change their prescription opioid medication misuse behaviors.	5.7 (1.8)	5.6 (1.7)	5.7 (1.8)
8. It is OK for physical therapists to refer their patients with prescription opioid medication misuse to a specialist to address the opioid misuse.	6.2 (1.5)	5.8 (1.6)	6.2 (1.5)
9. If the physical therapist asked me about prescription opioid medication misuse, regardless of whether I was misusing prescription opioids, I would answer truthfully.	6.1 (1.5)	6.0 (1.7)	6.2 (1.5)

Missing in question 1 = 1

Missing in question 2 = 4

Missing in question 3 = 4

Missing in question 4 = 7

Missing in question 5 = 6

Missing in question 6 = 3

Missing in question 7 = 6

Missing in question 8 = 3

Missing in question 9 = 3

Table 3.

The Association Between Patients’ Opioid Use Status and the Patient’s Perceptions Regarding Physical Therapists Addressing Opioid Misuse.

Variable	It is OK for physical therapists to ask their patients questions to find out if they have misused prescription opioid medications in the past. n = 784			It is OK for physical therapists to ask their patient questions about whether they are currently misusing prescription opioid medications. n = 783			It is OK for physical therapists to use questionnaires to determine if their patients are misusing prescription opioid medications. n = 783			It is OK for physical therapists to ask their patient why they are misusing prescription opioids. n = 783			It is OK for physical therapists to ask their patients about the frequency of their prescription opioid medication misuse. n = 781
	β (95% CI)		P	β (95% CI)		P	β (95% CI)		P	β (95% CI)		P	β (95% CI)		P
Opioid use	−0.08	(−0.43 to 0.27)	.64	−0.16	(−0.49 to 0.16)	.33	−0.07	(−0.40 to 0.25)	.66	−0.27	(−0.64 to 0.10)	.15	−0.28	(−0.62 to 0.07)	.11
Age	−0.00	(−0.01 to 0.00)	.21	−0.00	(−0.01 to 0.00)	.21	−0.01	(−0.01 to −0.00)	.03	0.00	−0.01 to 0.01)	.86	−0.01	(−0.01 to 0.00)	.07
Gender	0.05	(−0.21 to 0.30)	.71	−0.03	(−0.27 to 0.21)	.79	0.08	(−0.16 to 0.32)	.53	−0.06	(−0.33 to 0.12)	.68	−0.02	(−0.27 to 0.23)	.89
Race	0.07	(−0.45 to 0.58)	.80	0.03	(−0.44 to 0.51)	.89	0.11	(−0.37 to 0.59)	.66	0.10	−0.46 to 0.65)	.73	0.11	(−0.40 to 0.62)	.67
Variable	It is OK for physical therapists to assess their patients’ readiness to change their prescription opioid misuse behaviors. n = 784			It is OK for physical therapists to discuss/advise their patients to change their prescription opioid medication misuse behaviors. n = 784			It is OK for physical therapists to refer their patients with prescription opioid medication misuse to a specialist to address the opioid misuse. n = 781			If the physical therapist asked me about prescription opioid medication misuse, regardless of whether I was misusing prescription opioids, I would answer truthfully. n = 781
	β (95% CI)		P	β (95% CI)		P	β (95% CI)		P	β (95% CI)		P
Opioid use	−0.36	(−0.73 to 0.00)	.52	−0.8	(−0.45 to 0.29)	.67	−0.33	(−0.63 to −0.03)	.031*	−0.17	(−0.47 to 0.13)	.28
Age	−0.00	−0.10 to 0.00)	.40	−0.00	(−0.01 to 0.00)	.18	−0.00	(−0.01 to 0.00)	.15	0.01	(−0.00 to 0.01)	.08
Gender	0.01	−0.25 to 0.28)	.93	−0.08	(−0.34 to 0.18)	.57	0.06	(−0.15 to 0.28)	.57	0.08	(0.14 to 0.30)	.47
Race	−1.0	(−0.63 to 0.43)	.72	0.01	(−0.53 to 0.54)	.97	0.08	(−0.25 to 0.52)	.70	−0.09	(−0.54 to 0.36)	.71

^*Indicates significant values (P < .05); aOR = adjusted odds ratio; CI = confidence interval

DISCUSSION

Given that physical therapists are well positioned to address opioid misuse in patients with musculoskeletal conditions, we sought to (1) evaluate the patients perceptions of PTs addressing opioid misuse in their patients and (2) determine whether there were differences in these perceptions between those who had a history of exposure to prescription opioids while attending physical therapy compared to those without such exposure. This study is unique in that we are unaware of any other reports of the patients’ perceptions of PTs addressing opioid misuse. A notable finding of this work is that, for each opioid misuse-related item, the scores are clustered at the high end of the scale indicating overall support for PTs to address opioid misuse from the patient’s perspective. There are several potential explanations for this finding, which could, in part, be due to patients feeling that that they trust their PT.^20,21 PTs frequently manage patients’ rehabilitation needs longitudinally over several visits,^5,22,23 which could support the formation of a therapeutic alliance. When a strong therapeutic relationship exists between a patient and their PT, outcomes such as pain²⁴ and disability²⁵ are favorable. A therapeutic alliance may provide a foundation for PTs to have difficult conversations such as those about opioid misuse. Patient trust in their rehabilitation provider is a component of a therapeutic alliance.²⁶ Although, in the current study, we did not measure the patients’ trust in their physical therapist or patient-PT therapeutic alliance, a trusting relationship with a strong therapeutic alliance may have instilled the patient with the sense that they could have potentially difficult conversations with their PT about opioid misuse. PTs appear to form a strong therapeutic alliance with their patients with musculoskeletal conditions.^27,28 This strong therapeutic alliance may suggest that the physical therapy setting is an ideal setting with which to address opioid misuse.

An additional explanation is that media coverage^29–31 about the opioid crises in the United States could have made physical therapy patients generally aware that using prescription opioids in ways other than prescribed can lead to undesirable outcomes such as opioid use disorder, opioid overdose and death.³² Such awareness could lead patients to favorably view engagement in efforts to address the opioid crisis by all providers, including PTs.

The highest mean score among all patient perception questions was 6.2 (SD=1.5) for “It is OK for physical therapists to refer their patients with prescription opioid misuse to a specialist to address the opioid misuse.” We did not measure the patient’s preferences regarding whether the PT should address the opioid misuse versus referring the patient to a provider such a primary care provider or an addiction medicine specialist to address the opioid misuse. It is possible that the patients intuitively understand that there are challenges with managing patients with opioid misuse and they feel strongly that if the PT identifies a patient with opioid misuse, then a referral to a specialist is warranted.

The patients in our study had the lowest level of agreement for “It is OK for physical therapists to ask their patients why they are misusing prescription opioids,” which had the lowest mean score [5.6 (SD = 1.9)] among all the opioid-related items. This lower score could reflect a general aversion to being probed for the reasons behind the patient’s opioid misuse. Had the patients been asked to rate their agreement that it was OK for a primary care provider or an addiction specialist to ask their patient why they are misusing opioids, the mean level of agreement might have been higher. Nonetheless, the mean indicates that patients support PTs in engaging patients in such a sensitive conversation. That the mean score was the lowest among all opioid related items, could be explained by the patients perceiving that being asked why they are misusing prescription opioids is attached to negative judgements. Patients living with chronic pain report facing negative judgements about their opioid use based on the association of opioid medications with illicit drugs.^33,34 While it is unknown whether the patients in our study had chronic pain, it is possible that the lower score related to asking patients why are they misusing prescription opioids reflects an aversion to being negatively judged for their prescription opioid use.

An interesting finding in our study is that for all but one item (“It is OK for the physical therapist to refer their patients with opioid misuse to a specialist to address the opioid misuse”), there were no differences in the levels of agreement about PTs addressing opioid misuse for any other item. In some populations, the perceptions about aspects related to opioid use differ between those with exposure to prescription opioids compared to those without exposure to opioid use. For example, young adults who have taken prescription opioids as prescribed perceive higher prevalence of opioid misuse than young adults who have not been exposed to prescription opioids.³⁵ In adults with hip or knee osteoarthritis (OA), those taking prescription opioids for OA-related pain perceived the risks associated with taking opioids to be smaller than those not taking prescription opioids.³⁶ That the patients in our study who had been exposed to prescription opioids while attending physical therapy had lower agreement that PTs should refer their patients with opioid misuse to a specialist compared to patients attending physical therapy without such exposure may indicate a desire not to alert other providers that a patient could have opioid misuse. While speculation, feelings of shame may be present if a PT were to discuss referring the patient to their primary care provider or addiction specialist. Feelings of shame is commonly reported in patients undergoing treatment for opioid use disorder^37,38 and it is possible that similar feelings could be present in patients referred for opioid misuse.

The prevalence with which PTs routinely assess and document their patients’ prescription opioid dose is unknown. Physical therapy best practice includes a review of the patient’s medications, which includes the use of opioid medications.¹² We recommend that PTs routinely monitor their patients opioid dose throughout an episode of physical therapy care.⁹ Our nationwide survey of physical therapists indicates that 70.0% of physical therapists report that they never or rarely ask their patients about a history of opioid misuse.¹¹ Routine monitoring of patients in physical therapy should also include assessing for opioid misuse. Our results indicate that patients support such assessments.

Readers should interpret the results of this study with caution because of several limitations. The results cannot be generalized to other health care systems or other regions of the country. Respondents may have felt compelled to respond in a particular way given that they had recently attended a physical therapy visit. Therefore, social desirability response bias may have led to inaccurate responses.³⁹ Greater than 89% of the respondents were white, which may limit the generalizability to other races/ethnicities. Our survey did not include all possible questions that could measure patients’ perceptions about PTs addressing opioid misuse. It is possible that important perceptions were left unmeasured. The cross-sectional nature of the study does not allow us to infer causality between the patients’ history of taking opioid medication for pain while attending physical therapy and any opioid-related survey item. We targeted patients after their initial evaluation for physical therapy evaluation. Our results could be different had the patients been sent the survey after the entire episode of care (i.e., after multiple visits with a PT). We did not determine whether the respondents had opioid misuse. If our cohort was made up of patients with opioid misuse, respondents may have rated their agreement with the opioid misuse-related items differently. Finally, patients who choose not to complete the survey could be different in important ways from those who did complete to the survey. Therefore, our results could be subject to selection bias.

CONCLUSIONS

Patients with and without exposure to opioids who attend physical therapy support PTs addressing opioid misuse with their patients. If patients are willing to engage with PTs about potential opioid misuse, then PTs are more likely to be effective members of the health care team to address opioid misuse.