AN OPIOID EPIDEMIC

Since the increase in the prescription of opioids in the 1990s, the United States has seen a continued surge in opioid-related deaths, with 75% of the 91,977 drug overdose deaths in 2020 involving opioids1. In a cohort study, it was found that 70% of patients in the United States were prescribed opioids after minor surgeries (laparoscopic and arthroscopic procedures), compared with only 11% in Sweden2. Additionally, the mean dose of opioids prescribed was highest in the United States compared with Sweden and Canada2. Opioids continue to be prescribed for addressing chronic non-cancerous pain though there is no strong evidence to support their use3. Conversely, use of prescription opioids for over 90 days has been associated with increased risk of substance use disorder, decreased testosterone, respiratory depression, cardiac issues, fractures, immunosuppression, impaired cognitive and executive function, among other adverse effects4, 5. Opioid-induced hyperalgesia (OIH) is another common complication of prescription opioid use, with research suggesting OIH can occur with even short term use or after usage of large doses6. 

MECHANISMS OF DRY NEEDLING 

Dry needling (DN) offers itself as a viable alternative to opioids to address both acute post-surgical and chronic pain through its supraspinal and spinal analgesic effects. For acute pain, DN can inhibit inflammation through simulation of the hypothalamic-pituitary-adrenal (HPA) axis, which inhibits cox-2 and release of inflammatory cytokines7. This increased activation of the HPA axis also stimulates the production of beta endorphins, which serve as endogenous opioids8. Stimulation of opioid interneurons in the spine also occurs due to the production of oxytocin with DN7.This opioid-based pain reduction was supported by a study showing that use of Naloxone, an opioid antagonist, decreased the analgesic effects of DN8. In addition to the previously mentioned effects, electrical dry needling (EDN) has been shown to reverse C-fiber mediated central sensitization through the simulation of A∂ fibers, which would play a crucial role in addressing chronic pain7. Even needling distal sites improves more proximally located pain due to a release of histamine through mechanotransduction7. EDN results in the decreased activation of purinergic receptors, resulting in increased mechanical pain thresholds due to desensitization of spinal pain pathways from decreased supraspinal communication8. The multi-faceted positive effects of DN on opioid and non-opioid pain physiological pathways is strongly supported in recent literature. 

APPLICATIONS OF DN 

While more research is required to better understand the full breadth of DN application, there is strong evidence to support its use for acute and chronic pain. In a study comparing DN and IV morphine in emergency department care, investigators found that DN had a 92% success rate in decreasing pain by 50% compared with only 78% in the morphine group9. With post-surgical pain, a systematic review revealed that patients who received acupuncture after surgical procedures required fewer opioids and had less pain10. Additionally, a randomized and double-blinded placebo-controlled trial demonstrated that patients who received a single session of DN following anesthesia and prior to surgery had significantly less pain immediately after and one month following surgery11. In multiple systematic reviews, acupuncture has been classified as having strong positive evidence for addressing chronic low back pain, knee osteoarthritis, and cervical pain, with resulting improvements in pain and function12, 13, 14, 15. One study evaluated treatment of 17,922 patients with chronic pain and found that the effects of DN can last for over a year16. 

NEEDLING: WHAT’S THE POINT? 

DN is a unique tool to address and elicit positive physiological changes to improve patients’ functional outcomes and quality of life. Major adverse reactions–such as lower limb weakness, fainting, and infection–occur at a rate of <0.1%, with common minor adverse reactions including only small bleeding and bruising incidents16. Additionally, there were no associations between frequency of adverse events and practitioner age, level of training, or experience with DN16. Needling is, therefore, a non-addictive, non-pharmacologic, safe, cost-effective, and strongly supported intervention to make lasting changes on pain and function during acute, subacute, and chronic stages of pain. Through its synergistic work with endogenous opioid and non-opioid systems, DN can readily compliment, replace, or even aid to wean from opioid usage. As DN has been utilized for nearly 3,000 years in Eastern civilizations, it seems to be time for the United States to ditch the pills for pins. 

REFERENCES 

1. Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR MorbMortal Wkly Rep. 2011 Nov 4; 60(43):1487-1492.

2. Ladha KS, Neuman MD, Broms G, et al. Opioid Prescribing After Surgery in the United States, Canada, and Sweden. JAMA Netw Open. 2019;2(9):e1910734. doi:10.1001/jamanetworkopen.2019.10734

3. Eriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain: An epidemiological study. Pain. 2006;125(1-2):172–179.

4. Krashin D, Murinova N, Sullivan M. Challenges to treatment of chronic pain and addiction during the “opioid crisis.” Current Pain and Headache Reports. 2016;20(12):65. 

5. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of Internal Medicine. 2015;162(4):276–286. 

6. Yi P, Pryzbylkowski P. Opioid induced hyperalgesia. Pain Medicine. 2015;16(Suppl. 1):S32–S36.

7. Butts, Raymond & Dunning, James & Perreault, Thomas & Mourad, Firas & Grubb, Matthew. (2016). Peripheral and Spinal Mechanisms of Pain and Dry Needling Mediated Analgesia: A Clinical Resource Guide for Health Care Professionals. American Journal of Physical Medicine & Rehabilitation. 4. 10.4172/2329-9096.1000327. 

8. Roberson R, Tucker B, Kerna NA, et al. A safe “opioid” – is dry needling an efficacious alternative to opioids? Int J Complement Alt Med. 2019;12(1):6–8. DOI: 10.15406/ijcam.2019.12.00440

9. Grissa MH, Baccouche H, Boubaker H, et al.Acupuncture vs intravenous morphine in the management of acute pain in the ED. Am J Emerg Med. 2016;34:2112–2116.

10. Wu MS, Chen KH, Chen IF, et al.The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One. 2016;11:e0150367

11. Mayoral, O., Salvat, I., Martín, M. T., Martín, S., Santiago, J., Cotarelo, J., & Rodríguez, C. (2013). Efficacy of myofascial trigger point dry needling in the prevention of pain after total knee arthroplasty: a randomized, double-blinded, placebo-controlled trial. Evidence-based complementary and alternative medicine : eCAM, 2013, 694941. https://doi.org/10.1155/2013/694941

12. Cherkin DC, Sherman KJ, Avins AL, et al.A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009;169:858–866.

13.  Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MCEffectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2004;141:901–910.

14. Lin X, Huang K, Zhu G, Huang Z, Qin A, Fan SThe effects of acupuncture on chronic knee pain due to osteoarthritis: a meta-analysis. J Bone Joint Surg Am. 2016;98:1578–1585.

15. Liang Z, Zhu X, Yang X, Fu W, Lu AAssessment of a traditional acupuncture therapy for chronic neck pain: a pilot randomised controlled study. Complement Ther Med. 2011;19suppl 1S26–S32.

16. MacPherson H, Vertosick EA, Foster NE, et al.The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain. Pain. 2017;158:784–793.

17. Boyce, D., Wempe, H., Campbell, C., Fuehne, S., Zylstra, E., Smith, G., Wingard, C., & Jones, R. (2020). ADVERSE EVENTS ASSOCIATED WITH THERAPEUTIC DRY NEEDLING. International journal of sports physical therapy, 15(1), 103–113.