The Opioid Epidemic

This section was compiled by Frank M. Painter, D.C.
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Conditions That Respond Alternative Medicine Approaches to Disease

Association of Chiropractic Care With Receiving
an Opioid Prescription for Noncancer Spinal Pain
Within a Canadian Community Health Center:
A Mixed Methods Analysis

J Manipulative Physiol Ther 2022 (Aug 23); S0161-4754(22)00086-0 ~ FULL TEXT

Our analysis found that patients with spine pain who received chiropractic care were less likely to receive opioids compared to patients who did not receive chiropractic care. This relationship was most pronounced among patients with early access to chiropractic services. Four themes emerged in our qualitative interviews, including patient self-efficacy, access to chiropractic services, stigma regarding use of opioids, and impact of treatment, which provide a richer understanding of this association.

A Retrospective Analysis of Pain Changes and
Opioid Use Patterns Temporally Associated
with a Course of Chiropractic Care at a
Publicly Funded Inner-city Facility

J Can Chiropr Assoc 2022 (Aug); 66 (2): 107–117 ~ FULL TEXT

The results of the present study found a statistically and clinically significant pain reduction concomitant with publicly funded chiropractic management in a low-income population who utilized opioids. Additionally, a reduction in opioid use, compared to baseline, was found following a course chiropractic management at a multidisciplinary healthcare facility where the majority of patient referrals came from primary care physicians, and resulted in an endpoint of musculoskeletal care for the majority of individuals treated by the onsite chiropractors.

Health Care Resource Utilization in Management
of Opioid-Naive Patients With Newly
Diagnosed Neck Pain

JAMA Netw Open 2022 (Jul 1); 5 (7): e2222062 ~ FULL TEXT

Research has uncovered heterogeneity and inefficiencies in the management of idiopathic low back pain, but few studies have examined longitudinal care patterns following newly diagnosed neck pain. In this cross-sectional study, early imaging without subsequent intervention was associated with significantly increased health care spending among patients with newly diagnosed idiopathic neck pain. Early conservative therapy was associated with lower costs, even with increased frequency of therapeutic services, and may have reduced long-term care inefficiency.

Associations Between Early Chiropractic Care and
Physical Therapy on Subsequent Opioid Use Among
Persons With Low Back Pain in Arkansas

J Chiropractic Medicine 2022 (Jun); 21 (2): 67–76 ~ FULL TEXT

In this study we found that receipt of chiropractic care, though not PT, may have disrupted the need for opioids and, in particular, long-term opioid use (LTOU) in newly diagnosed LBP. These authors are to be praised for publishing this paper. When you look at their pedigrees, it's reasonable to imagine that they may have been looking to see that physical therapy was associated with reduced opioid use. Numerous studies have shown that chiropractic already has a well-established track record for low- to no-opioid use, so they would be the perfect comparison group for a study like this. We all know that third parties are looking for safe and cost-effective alternatives to “usual care”. In the past, a study favorable to chiropractic care, particularly one that used physical therapy as a comparison group, would never have been published, because of the long-standing medical bias against chiropractic care. So, let's tip our hats to this group of researchers for their hard work and honesty!

Association Between Chiropractic Care and Use of Prescription
Opioids Among Older Medicare Beneficiaries with Spinal Pain:
A Retrospective Observational Study

Chiropractic & Manual Therapies 2022 (Jan 31); 30: 5 ~ FULL TEXT

Older Medicare enrollees with spinal pain who saw both a chiropractor and a primary care physician had less than half the risk of filling an opioid prescription, as compared to those who received primary medical care alone. The association was most pronounced among those who saw a chiropractor within the first 30 days of care.

Increased Utilization of Spinal Manipulation by
Chiropractors to Tackle the Opioid Epidemic

Medical Care 2021 (Dec 1); 59 (12): 1039–1041 ~ FULL TEXT

Increased utilization of spinal manipulation performed by chiropractors may be one approach to dampening the opioid epidemic through practices that minimize the use of those drugs for conditions like low back pain where opioid prescribing remains high. [1] Opioids have been found to be ineffective for low back pain while causing multiple side effects such as addiction, drug diversion, and overdose. [2] In response to the opioid epidemic, over half of the states have made legislative changes limiting the quantity and duration of opioid prescriptions for acute pain. [3] In addition, the American College of Physicians has recommended spinal manipulation as part of the nonpharmacological firstline treatment for low back pain since 2017. [4] Efforts such as these have been impactful.

Initial Choice of Spinal Manipulation Reduces Escalation
of Care for Chronic Low Back Pain
Among Older Medicare Beneficiaries

Spine (Phila Pa 1976) 2021 (May 11) [EPUB] ~ FULL TEXT

SMT was associated with lower rates of escalation of care as compared to Opioid Analgesic Therapy (OAT).   Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy. Level of Evidence: 3.

"Like Peanut Butter and Jelly": A Qualitative Study
of Chiropractic Care and Home Exercise Among
Older Adults with Spinal Disability

BMC Geriatrics 2021 (Apr 23); 21 (1): 271

Older adults valued non-pharmacological treatment options that aided them in controlling spine-related symptoms, while empowering them to maintain clinical benefit gained after a course of chiropractic spinal manipulation and exercise. The complimentary nature of provider-delivered and active care modalities may be an important consideration when developing care plans. This study underscores the importance of understanding participants' values and experiences when interpreting study results and applying them to practice.

Complementary, Integrative, and Nondrug Therapy Use for
Pain Among US Military Veterans on Long-term Opioids

Medical Care 2020 (Sep); 58 Supp l 2 9S: S116–S124 ~ FULL TEXT

In conclusion, our study found that US VA patients on long-term opioid therapy (LTOT) for chronic pain commonly use nondrug therapies to manage pain, that observed nondrug therapy use classes reflect clinically relevant functional groups, and that patient characteristics are associated with use of different nondrug therapies. Further exploration of factors affecting nondrug therapy access and use for specific subpopulations, such as use of exercise/movement therapy by people with high pain interference, may enable implementation of nondrug and complementary and integrative health (CIH) therapy for chronic pain and expand safe, effective pain treatment options for people prescribed LTOT.

Association of Initial Provider Type on Opioid
Fills for Individuals With Neck Pain

Archives of Phys Med and Rehabilitation 2020 (Aug); 101 (8): 1407–1413 ~ FULL TEXT

Compared to patients with neck pain who saw a primary health care provider, patients with neck pain who initially saw a conservative therapist were 72%–91% less likely to fill an opioid prescription in the first 30 days, and between 41%–87% less likely to continue filling prescriptions for 1 year. People with neck pain who initially saw emergency medicine physicians had the highest odds of opioid use during the first 30 days (OR, 3.58; 95% CI, 3.47–3.69; P<.001).

Association Between Chiropractic Use and Opioid Receipt
Among Patients with Spinal Pain: A Systematic
Review and Meta-analysis

Pain Medicine 2019 (Sep 27) [Epub] ~ FULL TEXT

This systematic review demonstrated an inverse association between chiropractic use and opioid receipt among patients with spinal pain. Overall, chiropractic users had a 64% lower odds of receiving an opioid prescription than nonusers. Further research is warranted to assess this association and the implications it may have for case management strategies to decrease opioid use.

Observational Retrospective Study of the Association
of Initial Healthcare Provider for New-onset
Low Back Pain with Early and Long-term Opioid Use

BMJ Open. 2019 (Sep 20); 9 (9): e028633 ~ FULL TEXT

Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

Access to Chiropractic Care and the Cost of
Spine Conditions Among Older Adults

American Journal of Managed Care 2019 (Aug); 25 (8): e230–e236 ~ FULL TEXT

This study is among the first to examine whether access to chiropractic care, a health service that provides a significant amount of the nation’s conservative management of nonspecific back pain, has any effect on Medicare spending. We found some evidence of a relationship between lower accessibility of chiropractic care and higher spending on diagnostic imaging and testing. Future work is required to determine if indeed access to chiropractic care for Medicare beneficiaries in any way breaks the pathway to care that is discordant with practice guidelines

Guideline Recommendations on the Pharmacological
Management of Non-specific Low Back Pain in
Primary Care – Is There a Need to Change?

Expert Rev Clin Pharmacol. 2019 (Feb); 12 (2): 145–157 ~ FULL TEXT

Upcoming guideline updates should explicitly shift their focus from pain to function and from pharmacotherapy to non-pharmacological treatments; patient education is important to make sure NSLBP patients accept these changes. To improve the quality of NSLBP care, the evidence-practice gap should be closed through guideline implementation strategies.

Coverage of Nonpharmacologic Treatments for Low Back
Pain Among US Public and Private Insurers

JAMA Network Open 2018 (Oct 5); 1 (6): e183044 ~ FULL TEXT

Insurers are increasingly recognized as influential stakeholders that are well positioned to drive changes in pain treatment practices. One key component of such changes is the greater use of nonpharmacologic approaches to managing chronic, noncancer pain, as has been recommended by the Centers for Disease Control and Prevention, [10] the President’s Commission on Combating Drug Addiction and the Opioid Crisis, [8] and others. [25] To our knowledge, our work represents the most comprehensive assessment of coverage policies regarding the medical necessity, coverage, and management of nonpharmacologic treatments for back pain.

A SMART Design to Determine the Optimal Treatment of
Chronic Pain Among Military Personnel

Contemp Clin Trials. 2018 (Oct); 73: 68–74 ~ FULL TEXT

Chronic pain is a leading cause of disability among active duty service members in the U.S. armed forces. Standard rehabilitative care and complementary and integrative health therapies are used for chronic pain rehabilitation. However, the optimal sequence and duration of these therapies has yet to be determined. This article describes a sequential multiple assignment randomized trial (SMART) protocol being used to identify the optimal components and sequence of standard rehabilitative care and complementary and integrative health therapies for reducing pain impact and improving other patient outcomes. Active duty service members referred to Madigan Army Medical Center for treatment of chronic pain are being recruited to the Determinants of the Optimal Dose and Sequence of Functional Restoration and Integrative Therapies study.

Characteristics of Chiropractic Patients Being Treated
for Chronic Low Back and Neck Pain

J Manipulative Physiol Ther. 2018 (Sep); 27 (Suppl 6): 901–914 ~ FULL TEXT

This study provides insight into the characteristics of patients who are successfully managing their chronic low back pain (CLBP) and chronic neck pain (CNP). Findings of this descriptive study of a large sample of chiropractic patients with CLBP or CNP reveal this sample to be similar to those found in other studies of chiropractic patients: highly-educated, non-Hispanic, white women, with at least partial insurance coverage for chiropractic. These individuals have also been in pain and using chiropractic care for years. Most came to chiropractic after trying other types of care, and just under a third continued to receive other concurrent care for their pain. Prior to chiropractic, they saw the best results with massage therapy and acupuncture and reported high levels of belief in the success of chiropractic in reducing their pain.

Association Between Utilization of Chiropractic Services for
Treatment of Low-Back Pain and Use of Prescription Opioids

J Altern Complement Med. 2018 (Jun); 24 (6): 552–556 ~ FULL TEXT

The adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower among recipients odf chiropractic care compared with nonrecipients (odds ratio 0.45; 95% confidence interval 0.40–0.47; p < 0.0001). Average charges per person for opioid prescriptions were also significantly lower among recipients.

Guideline for Opioid Therapy
and Chronic Noncancer Pain

CMAJ. 2017 (May 8); 189 (18): E659–E666 ~ FULL TEXT

This new Canadian guideline published today (May 8, 2017) in the Canadian Medical Association Journal (CMAJ) strongly recommends doctors to consider non-pharmacologic therapy, including chiropractic, in preference to opioid therapy for chronic non-cancer pain. The guideline is the product of an extensive review of evidence involving input from medical, non-medical, regulatory, and patient stakeholders.

Cannabis for Pain and Headaches: Primer
Curr Pain Headache Rep. 2017 (Apr); 21 (4): 19 ~ FULL TEXT

Synthetic cannabinoids are being developed and synthesized from the marijuana plant such as dronabinol and nabilone. The US Food and Drug Administration approved the use of dronabinol and nabilone for chemotherapy-associated nausea and vomiting and HIV (Human Immunodeficiency Virus) wasting. Nabiximols is a cannabis extract that is approved for the treatment of spasticity and intractable pain in Canada and the UK. Further clinical trials are studying the effect of marijuana extracts for seizure disorders. Phytocannabinoids have been identified as key compounds involved in analgesia and anti-inflammatory effects. Other compounds found in cannabis such as flavonoids and terpenes are also being investigated as to their individual or synergistic effects. This article will review relevant literature regarding medical use of marijuana and cannabinoid pharmaceuticals with an emphasis on pain and headaches.

Provider and Patient Perspectives on Opioids and
Alternative Treatments for Managing Chronic Pain:
A Qualitative Study

BMC Fam Pract. 2017 (Mar 24);   17 (1):   164 ~ FULL TEXT

Despite widespread dissatisfaction with opioid medications for pain management, many practical barriers challenged access to other options. Most of the participants' perceived acupuncture and chiropractic (A/C) care as helpful for short term pain relief. We identified that problems with timing, expectations, and plan coverage limited A/C care potential for pain relief treatment.   CONCLUSIONS:   These results suggest that education about realistic expectations for chronic pain management and therapy options, as well as making acupuncture and chiropractic (A/C) care more easily accessible, might lead to more satisfaction for patients and providers, and provide important input to policy makers.

Opioid Use Among Low Back Pain Patients in Primary Care:
Is Opioid Prescription Associated with Disability
at 6-month Follow-up?

Pain 2013 (Jul); 154 (7): 1038–1044 ~ FULL TEXT

Our findings indicate that even after adjusting for a substantial number of potential confounders, opioids were associated with slightly worse functioning in back pain patients at 6-month follow-up. Further research may help us to understand the mechanisms underlying these findings and inform clinical decisions regarding the usefulness of opioids for back pain.

Aging Baby Boomers and the Rising Cost of Chronic Back Pain:
Secular Trend Analysis of Longitudinal Medical Expenditures
Panel Survey Data for Years 2000 to 2007

J Manipulative Physiol Ther. 2013 (Jan); 36 (1): 2–11

The prevalence of back pain, especially chronic back pain, is increasing. To the extent that the growth in chronic back pain is caused, in part, by an aging population, the growth will likely continue or accelerate. With relatively high cost per adult with chronic back pain, total expenditures associated with back pain will correspondingly accelerate under existing treatment patterns. This carries implications for prioritizing health policy, clinical practice, and research efforts to improve care outcomes, costs, and cost-effectiveness and for health workforce planning.

The Association of Complementary and Alternative Medicine
Use and Health Care Expenditures for Back and Neck Problems

Med Care. 2012 (Dec); 50 (12): 1029–1036 ~ FULL TEXT

While health care conversations increasingly mention chiropractic care as a viable option for back and neck pain – and research increasingly supports its utility from a clinical standpoint – this nationwide study of complementary and alternative medicine (CAM)-related health care expenditures by 12,000–plus adults (ages 17 and older) with spinal conditions lends support to the suggestion that CAM in general, and chiropractic specifically, is also a cost-effective alternative to traditional medical care.

Advancements in the Management of Spine Disorders
Best Pract Res Clin Rheumatol. 2012 (Apr); 26 (2): 263–280 ~ FULL TEXT

Despite, or perhaps because of its impact, spinal disorders remain one of the most controversial and difficult conditions for clinicians, patients and policymakers to manage. This paper provides a brief summary of advances in the understanding of back and neck pain over the past decade as evidenced in the current literature. This paper includes the following sections: a classification of spinal disorders; the epidemiology of spine pain in the developed and developing world; key advancements in biological and biomechanical sciences in spine pain; the current status of potential methods for the prevention of back and neck pain; rheumatological and systemic disorders that impact the spine; and evidence-based surgical and non-surgical management of spine pain. The final section of this paper looks to the future and proposes actions and strategies that may be considered by the international Bone and Joint Decade (BJD), by providers, institutions and by policymakers so that we may better address the burden of spine disorders at global and local levels.

Chronic Pain Reconsidered
Pain. 2008 (Aug 31); 138 (2): 267–276 ~ FULL TEXT

Chronic pain has been traditionally defined by pain duration, but this approach has limited empirical support and does not account for chronic pain's multi-dimensionality. This study compared duration-based and prospective approaches to defining chronic pain in terms of their ability to predict future pain course and outcomes for primary care patients with three common pain conditions: back pain (n = 971), headache (n = 1078), or orofacial pain (n = 455).   At baseline, their chronic pain was classified retrospectively based on Pain Days in the prior six months and prospectively with a prognostic Risk Score identifying patients with "possible" or "probable" chronic pain.

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