As the scope of America’s opioid epidemic has become apparent over the last decade, doctors have dramatically reined in opioid prescriptions. The number of opioid prescriptions peaked in 2012 at more than 255 million before beginning to recede, and by 2020 had fallen to about 142 million, according to the U.S. Centers for Disease Control and Prevention—the lowest level in 15 years.
But the dangers of opioid addiction and misuse remain high, especially for at-risk populations. One such group is athletes who are given opioids to aid in their recovery from sports injuries. A recent systemic review of research published in the journal Sports Health found that use of opioids during an athlete’s playing career—even during high school—to be predictive of post-retirement use.
Athletes who play contact sports are at particular risk of misusing opioids, according to research led by University of Michigan epidemiologist Philip Veliz, Ph.D. One reason is that those athletes often belong to peer networks where it can be relatively easy to get more of the drugs after an athlete runs out of prescription pills—especially during those earlier years when opioids and opioid prescriptions were handed out more readily.
As the United States continues to grapple with an opioid addiction crisis that can have profound implications on both physical and mental health, exploring the benefits of integrative care for pain management and injury recovery is making strides.
“The knowledge around this now is much more pervasive, and we understand that [opioid over-prescription] wasn’t the route that we needed to take. Now, the question is what is the appropriate way to manage pain for these kids when they’re injured,” says Dr. Veliz, assistant research professor at the University of Michigan School of Nursing’s Applied Biostatistics Laboratory, and associate director of the university’s Sport, Health and Activity Research and Policy Center. “Alternative and non-medicinal therapies need to be brought to the table, especially because it seems like athletes will be more receptive—why wouldn’t they choose an alternative therapy that’s rooted in physical activity over a therapeutic medical solution like an opioid?”
Integrative Therapies Ascending as an Opioid Alternative
Massage therapy is among several treatments to which health care providers are turning as a complement to or alternative for opioids, along with physical therapy and acupuncture. Yet the medical establishment has yet to coalesce around a specific regimen, in part because even with the increase in solid research around the benefits of massage therapy in recent years, more peer-reviewed, evidence-based research is still needed.
Addiction experts are optimistic about the potential of integrative approaches involving massage—but they also know it’s hard to affect the trajectory of mainstream medical practice without a strong research base. And that research base is hard to establish without large-scale funding of the sort that the pharmaceutical industry often provides to validate the performance of its own emerging therapeutics.
“Integrative therapies just do not have the same funding support for research that pharmaceuticals do,” says Erin Bonar, Ph.D., associate professor of psychiatry at the University of Michigan Addiction Center, and lead investigator on a current study focused on youth opioid prevention for the federal National Institute on Drug Abuse.
Despite that financial disadvantage, however, there is new research on the effectiveness of massage as a therapy to alleviate sports injuries—for example, faculty from Shanghai University of Traditional Chinese Medicine are currently conducting research for one such study. And a 2020 study in the journal BMJ Open Sport & Exercise Medicine by a team of researchers at the University of Sheffield in Britain found that massage therapy may be effective in mitigating delayed-onset muscle soreness.
The evidence base “is growing—as is the consensus that these are approaches we need to be investigating,” says Dr. Bonar.
Massage therapists who work to reduce pain among athletes know firsthand the positive affect massage can have. Jill Borcich, LMT, owner of Jill Borcich Massage Therapy in Cornelius, NC, works with a range of athletes, from NASCAR pit crews to cyclists, weightlifters and professional football players, and has a deep reservoir of anecdotal evidence that techniques such as cupping, dry needling and trigger-point massage can effectively reduce pain from sports injuries.
“I can tell you what my clients come back and tell me,” Borcich says. Opioids “put a bandaid over the pain, but they won’t prompt your body’s innate ability to heal itself in the same way massage does.”
Massage therapists, in contrast, are “encouraging better circulation and allowing oxygen-rich blood to get to the tissues so they can heal,” Borcich says.
Borcich can tick off a series of client stories where massage enabled high-school athletes to compete pain-free without opioids: an equestrian who gained relief from headaches after a fall; a baseball pitcher who not only gained relief from back pain, but who also gained flexibility in the bargain; and a dancer who gained mobility as well as relief from hip and calf pain.
Many doctors now are embracing massage therapy as a pain relief alternative. The evidence base for massage may not rival that of pharmacological therapies yet, but doctors also value something that massage has in its favor: Unlike opioids, it carries minimal risk of harm.
“The most important thing is to offer lots of options, lots of alternatives to opioids, and it’s great that massage is on the table as one of those options,” says Eve Klein, M.D., medical director at CODA, an addiction-recovery center based in Portland, OR. “We need all the options on the table, so that whatever a person is willing to engage in that’s safe and might be effective, we’re not closing those doors.”
Unmasking the Risks of Playing Through Pain
There’s a sense of urgency in Dr. Klein’s words that speaks to a lingering issue: Even though opioid prescriptions are waning, prescription pain relievers retain a strong allure among athletes. One reason is that athletes often are fiercely competitive and goal-oriented, and the notion of missing a season-defining game or tournament can be a traumatic prospect. Opioids and other prescription pain-relievers can mask pain and enable athletes to continue to perform, even if there are long-term health risks—an option some athletes will choose despite the risks, given their investment in the season at hand.
“Opioids can be used to mask pain and injury in potentially harmful ways that don’t allow the body to signal to them, ‘We need to take a break,’” Dr. Klein says. “We know pain and injuries get worse when people push through—even though I also know that conflicts with the goals of sports at some points.”
To that end, a 2018 white paper from the U.S. Department of Health and Human Services specifically calls out the contradictions of youth sports. On one hand, competition can lead to injury, which can lead to opioids and all the associated risks. But research also shows that youths who play sports are less likely to fall prey to opioid addiction than those who don’t. The white paper’s ultimate recommendation is education: informing young athletes, parents and care providers about the risks and benefits of opioids, as well as the existence of integrative therapies like massage. Some state-level agencies have done just that, such as the Massachusetts Interscholastic Athletic Association, which cautions injured athletes that “Opioids for pain should be considered only if recommended by a physician and only when other approaches have not provided relief.”
That advice is offered amidst the backdrop of the opioid crisis, as health care providers look for a better way. That’s where the promise of integrative care shines. An integrative combination of massage, chiropractic and physical therapy, for example, offers the hope of meaningful pain relief and healthy recovery, without the risk of causing greater harm.
“We want to be part of that wellness puzzle, where different providers come together to give them the best care possible,” says Borcich. “That trumps any pain medicine that you’re ever going to take.”
Sports Massage-Adjacent: Assisted Stretching
Sports massage differs from other forms of massage therapy in that it is focused on enhancing athletic performance, which is accomplished using targeted massage aimed at alleviating muscle soreness after exertion, for example, or to address pain resulting from soft-tissue injuries such as muscle strains or tendinitis.
An additional, emerging practice among some massage therapists focused on sports massage is assisted stretching. When in scope of practice, the massage therapist and athlete work together to stretch key muscle groups, with the goal of increasing flexibility, as well as relieving pain. One such technique, Proprioceptive Neuromuscular Facilitation, aims to improve both flexibility and range of motion by stretching a muscle group, then introducing resistance and contracting the muscle while it remains in the stretched position, and then stretching the muscle once again.
“Combined with massage, [assisted stretching] is another strategy that can be highly effective,” says Jill Borcich, LMT, owner of Jill Borcich Massage Therapy in Cornelius, NC.