THE OPIOID EPIDEMIC CONTINUES UNABATED
The opioid epidemic continues unabated. According to the Centers for Disease Control and Prevention (CDC), in a span of 17 years (1999-2016), more than 350,000 people died from an overdose involving opioids. Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014, yet there has been no overall change in the levels of pain Americans report. In 2016, the number of overdose deaths involving opioids (including both prescription and illegal opioids) was five times higher than in 1999.
In 2017, the Department of Health and Human Services (HHS) declared the opioid epidemic a public health emergency and announced a 5-Point Strategy to fight the opioid crisis. Unfortunately, the numbers since then have not improved. Since Q3 2016 through Q3 2017, the number of opioid deaths has increased approximately 30 percent, according to a recent report from the CDC.
While the nation’s attention on the opioid epidemic has heightened, interest in options for non-pharmacological care for pain has also increased. More consideration is being given to chiropractic care as a safe, effective, drug-free solution – especially for people with low back, neck and headache pain. Doctors of chiropractic (DCs) are specifically trained to diagnose, evaluate and provide non-pharmaceutical care and rehabilitation to individuals suffering from acute, subacute and chronic back, low back and neck pain, headaches, neuro-musculoskeletal conditions and other related syndromes
MAKING THE CASE FOR CHIROPRACTIC
Chiropractic has an established body of evidence demonstrating its effectiveness in pain management. In fact, there is more evidence for the efficacy of chiropractic care than there is for the drug-based care that most physicians are taught to favor. Multiple studies and clinical trials support that chiropractic care is better suited to manage and relieve pain than the use of pharmaceuticals.
In March 2018, The Lancet, one of the oldest, peer-reviewed medical journals in the world, published a three-part series on low back pain, which addresses the related ailment, the disability caused by low back pain and provides call-to-actions to meet the challenges associated with the prevention and management of low back pain. With up to 80 percent of the population bound to experience back pain at some point in their lives, the study shows the education and action items necessary to establish more effective, patient-centered care, which includes spinal manipulation. Doctors of chiropractic perform 94 percent of all spinal manipulations in the U.S.
Another recent example are the clinical trial results published in March 2018 in the Journal of the American Medical Association (JAMA) which found that the use of opioid v. non-opioid medication therapy for patients with moderate to severe chronic back, hip or knee osteoarthritis pain “did not result in significantly better pain-related function over 12 months.”
Published in April 2018, JAMA describes the formation of a new Pain Management Collaboratory. This joint project between the National Institutes of Health (NIH), Department of Defense and Veterans Affairs (VA) is using $81 million in grants to create a six-year, evidence-based study of non-drug approaches to pain management at VA hospitals around the country.
What sets this initiative apart is that spinal manipulation/chiropractic, behavioral therapy and the other pain management strategies being studied by the Pain Management Collaboratory are not being treated as “Complementary Alternative Medicine (CAM),” to use the industry vernacular. Instead, they are being considered as a first choice for patients suffering from many forms of pain.
Then there are the guidelines now being published by various medical groups. The American College of Physicians, after a review of more than 150 studies, concluded that physicians should consider spinal manipulation and other non-drug therapies as their first option for treating acute, subacute and chronic lower back pain. Guidelines published in the Canadian Medical Association Journal strongly recommend non-pharmacologic therapy, including chiropractic, before using opioid care for chronic non-cancer pain.
The Joint Commission and America’s Health Insurance Plans (AHIP) have issued similar guidance on the role of non-pharmacologic options in pain management, while the CDC, the U.S. Food and Drug Administration and the Institute of Medicine, among other organizations, have also called for early use of non-pharmacologic approaches to pain and pain management.
A June 2018 study published in the Journal of the American Medical Association’s online JAMA Network Open stated that private insurers, Medicare and Medicaid policies often miss opportunities to encourage patients to take safer, more effective alternatives to prescription opioids.
The study revealed an emphasis on increasing opioid utilization management and identifying high-risk prescribers and patients, rather than promoting comprehensive strategies to improve care of chronic pain or better integrating pharmacologic and non-pharmacologic alternatives to opioids.
BILLS TO SUPPORT CHIROPRACTIC
State governments are recognizing the value of chiropractic care and are passing laws in support of its role in effective, non-pharmacological pain management. Two monumental legislative bills in the State of Washington and one in West Virginia were recently passed in support of the chiropractic profession.
In Washington, the Prior Authorization bill allows patients up to six consecutive visits of chiropractic care in a new episode of care – defined as a new or recurrent condition for which the patients have not been treated for in the previous 90 days – without prior authorization. The Fair Pay bill ensures fair payment for DCs who provide spinal manipulation.
In West Virginia, Senate Bill 273 “Reducing Use of Certain Prescription Drugs” was recently signed into law. The purpose of the bill is to reduce the overuse of prescriptions of opioids and create a method to provide alternative care plans. Under the bill, healthcare practitioners treating a patient “for any of the myriad conditions that cause pain” will be required to refer the patient to alternative care before prescribing an opioid.
MAKING THE CASE FOR CHIROPRACTIC
According to the CDC, healthcare providers, including those in primary care settings, report concern about opioid-related risks of addiction and overdose, as well as insufficient training in pain management. Although prescription opioids can help manage some types of pain, there is not enough evidence that opioids improve chronic pain, function and quality of life. Moreover, long-term use of opioid pain relievers for chronic pain can be associated with abuse and overdose, particularly at higher dosages.
A study led by investigators at the Palmer Center for Chiropractic Research, in conjunction with the RAND Corporation and the Samueli Institute, makes the case that chiropractic care should be integral to the care plan for pain, not complementary. The study found that patients suffering from low back pain who received chiropractic care in addition to usual medical care had better short-term improvements in low back pain intensity and pain-related disability when compared to those who received usual medical care alone.
Results of this groundbreaking research were released in the JAMA Network Open. The study – the largest randomized clinical trial in chiropractic research in the U.S. to-date – took place from September 2012 to February 2016 and involved 750 active-duty U.S. military personnel at three sites across the country.
Low back pain is the leading cause of physical disability worldwide. The prevalence of low back pain among U.S. adults is estimated at 20 percent, with 50 to 80 percent of people reporting a significant episode at some point in their life. Low back pain is also one of the most common causes of disability in U.S. military personnel.
The results found that among active-duty U.S. military personnel, patients who received usual medical care plus chiropractic care reported a statistically significant moderate improvement in low back pain intensity and disability at six weeks compared with those who received usual care alone. The study further recommends that chiropractic care be included as a component of multidisciplinary healthcare for low back pain.
These findings are critical as the U.S. healthcare system looks for ways to implement existing national guidelines from groups such as the American College of Physicians and The Joint Commission that recommend non-drug care, such as spinal manipulative therapy, as the first-line of care for low back pain.
Doctors of chiropractic (DCs) provide conservative care focused on diagnosis, care and co-management, or referral for neuro-musculoskeletal conditions, including low back pain. The primary clinical intervention procedure by DCs is spinal manipulation or spinal adjustment.
The opioid epidemic has led many Americans, insurance companies, government leaders and medical professionals to be more open to enhancing their education about safe opioid prescribing and effective pain management. There is growing recognition and appreciation of the benefits of chiropractic care as an effective first-line, non-pharmacological care option for acute, subacute and chronic pain. As the use of spinal manipulation for pain management increases, we can expect to see a correlating decrease in the amount of prescription opioids in the future.
•115 people die each day from opioid-related drug overdoses.
•An estimated one out of five patients with non-cancer pain or pain-related diagnoses are prescribed opioids in office-based settings.
•More than 40% of all U.S. opioid overdose deaths in 2016 involved a prescription opioid.
•The most common drugs involved in prescription opioid overdose deaths include: Methadone, Oxycodone (such as OxyContin®) and Hydrocodone (such as Vicodin®).
•Nearly 80% of heroin users reported misusing prescription opioids prior to heroin.
Cliff Atwell, B.S., D.C.