A Call to Action: How Physical Therapy Can Address the Opioid Crisis

Updated November 21, 2025

The opioid crisis has become a significant public health issue, with over 100,000 overdose deaths recorded in 2022 alone.¹ While opioids can be effective for managing acute pain after serious injury or surgery, they are easy to misuse and not effective for long-term pain management. Low back pain is one of the most common conditions for which opioids are prescribed, yet these medications do not address the underlying causes of chronic low back pain. Physical therapy (PT) offers a safe, effective alternative to opioids by treating pain at its source and improving long-term function. By addressing movement dysfunction, muscle imbalances, and nervous system sensitization, PT helps patients regain mobility and reduce their reliance on medication.

Opioids work by binding to receptors in the brain and spinal cord to block pain signals and release dopamine, creating a powerful sense of relief and even euphoria. However, prolonged use can lead to tolerance, requiring higher doses for the same effect, which increases the risk of dependence, addiction, and overdose.²

Over time, repeated opioid exposure can lead to opioid-induced hyperalgesia, a condition where the nervous system becomes overly sensitive where even mild stimuli are perceived as painful. Instead of dulling pain, opioids may worsen it. This can lead individuals to use higher doses, increasing the risk of overdose and reinforcing a cycle of drug dependence. Yet, for many conditions such as chronic low back pain and osteoarthritis, opioids are often prescribed without addressing the mechanical and neurological causes of discomfort. This can prolong the pain experience and hinder recovery.

What, then, can be done to address issues of chronic pain? Physical therapy is an evidence-based, non-invasive approach to managing chronic low back pain that targets the root cause instead of just masking symptoms. Key PT strategies include: pain neuroscience education (PNE), exercise therapy, manual therapy, graded exposure therapy, and mind-body approaches. 

PNE teaches patients how pain works, helping them understand why symptoms may persist even after tissues have fully healed which is typically within 8 to 12 weeks. When pain continues beyond the expected healing window, it often reflects sensitization of the central nervous system rather than ongoing tissue damage. Educating patients about these mechanisms empowers them to interpret their symptoms more accurately and reduces fear-based avoidance.

Exercise and manual therapy are foundational PT tools. A trained therapist can prescribe exercises that promote tissue healing, mobility, and strength, while skilled manual therapy helps decrease pain and calm a sensitized nervous system. PT also uses graded exposure to gradually reintroduce movements that feel threatening so patients can rebuild confidence and reduce pain over time without relying on medication. Incorporating practices like breathwork, yoga, Pilates, and mindfulness further regulates the nervous system, enhancing the body’s resilience to stress . 

These clinical strategies are supported by decades of research comparing PT to opioid-based treatment approaches. As early as, 1997 systematic reviews³ had already identified manipulation, exercise therapy, and certain medications (such as NSAIDs and muscle relaxants) as the most effective treatments for nonspecific low back pain. A 2018 randomized controlled trial published in JAMA⁴ found that opioids were no more effective, and in some cases less effective, than nonopioid treatments for moderate to severe chronic low back pain. The nonopioid group experienced greater reduction in pain intensity, along with fewer adverse effects from medication.

A growing body of evidence supports the effectiveness of PT in reducing the need for opioids. A 2018 study in JAMA Network Open found that patients with neck, shoulder, low back, or knee pain who received PT within 30 days of diagnosis were 10% less likely to use opioids long-term.⁵ A study in The Journal of Orthopedic & Sports Physical Therapy found that PT is more effective than opioids for reducing pain-related disability.⁶ Also, the CDC’s 2022 clinical guidelines recommend PT as a first-line treatment for chronic pain before considering opioids.⁷

Beyond large population studies, smaller controlled analyses have more deeply examined how PT-first models influence real-world outcomes for chronic low back pain. A 2020 study published in Mental Health Clinician further supports the benefits of a PT-first approach for chronic low back pain.⁸ The single-center retrospective chart review included 180 patients with chronic low back pain for at least three months who completed ≥6 PT visits. Patients were divided into three groups: physical therapy first (PTF), opioids first (OF), and PTF combined with the Oswestry Disability Index (PTF + ODI), with 60 patients in each group. 

The ODI is a patient-reported questionnaire that measures disability related to low back pain across daily activities such as sleep, lifting, work, social participation, and travel. In the PTF + ODI group, patients experienced a mean 11.9% reduction in disability, with 61.7% achieving a clinically meaningful improvement of at least 10% (P < .001). These findings underscore PT’s ability to improve not just pain, but functional capacity and quality of life.

The study also found important differences in treatment persistence. The OF group had a dropout rate of 68.3%, much higher than that of the PTF group (38.3%). PT failure, meaning the patient required opioid therapy, occurred in only 3.3% of the PTF group, compared with 60% in the OF group. When considering why these differences occurred, it is important to recognize that those in the OF group were more likely to have comorbidities such as depression and a history of falls, factors known to impede recovery rates. This group may be harder to reach once these comorbidities appear which further highlights the importance of early PT intervention to avoid chronic opioid use. 

Medication use also decreased following PT. Opioid use in the OF group dropped by 48.3%, and nonopioid medication use fell by 29.9% in the OF group and 42.8% in the PTF group. Although not all changes reached statistical significance, the overall trend suggests that PT reduces reliance on medications across the board.

Overall, this study highlights improved functionality of patients receiving PT with or without opioid use. It also showcases how PT can reduce the use of medications in general which reduces unwanted side effects.

To fully realize PT’s potential as a frontline intervention, systemic changes are needed. These include expanding insurance coverage for PT services (including Medicare and Medicaid) for common conditions like low back pain, improving referrals and education from other healthcare providers, and strengthening public health campaigns that highlight non-drug options for pain management.

As the healthcare system continues to address the opioid epidemic, prioritizing PT as a first-line intervention is a critical step toward safer, more sustainable pain care.

References

1. National Institute on Drug Abuse. Drug Overdose Deaths: Facts and Figures. National Institute on Drug Abuse website. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates. Published August 21, 2024. Accessed March 29, 2025.

2. National Institute on Drug Abuse. Prescription Opioids DrugFacts. National Institute on Drug Abuse website. https://nida.nih.gov/publications/drugfacts/prescription-opioids. Published June 1, 2021. Accessed March 29, 2025.

3. van Tulder M, Koes B, Bouter, Lex M. Conservative Treatment of Acute and Chronic Nonspecific Low Back Pain: A Systematic Review of Randomized Controlled Trials of the Most Common Interventions. Spine. 1997; 22(18): 2128-2156. 

4. Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872–882. doi:10.1001/jama.2018.0899

5. Sun E, Moshfegh J, Rishel CA, Cook CE, Goode AP, George SZ. Association of Early Physical Therapy With Long-term Opioid Use Among Opioid-Naive Patients With Musculoskeletal Pain. JAMA Netw Open. 2018;1(8):e185909. doi:10.1001/jamanetworkopen.2018.5909

6. Mintken P, Moore J, Flynn T. Physical Therapists Role in Solving the Opioid Epidemic. JOSPT. 2018;48(5). doi:10.2519/jospt.2018.0606

7. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep. 2022;71(No. RR-3):1–95. doi:10.15585/mmwr.rr7103a1

8. Martin S, Tallian K, Nguyen VT, van Dyke J, Sikand H. Does early physical therapy intervention reduce opioid burden and improve functionality in the management of chronic lower back pain?. Mental Health Clinician. 2020;10(4):215–221. doi: 10.9740/mhc.2020.07.215

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