Medical Care 2021 (Dec 1); 59 (12): 1039–1041 ~ FULL TEXT
Benjamin J. Eovaldi, DO and Brad McAlpine, DC
Department of Family Medicine and Community Health,
University of Massachusetts Medical School,
MA Hudsonville Chiropractic,
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.  Opioids have been found to be ineffective for low back pain while causing multiple side effects such as addiction, drug diversion, and overdose.  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.  In addition, the American College of Physicians has recommended spinal manipulation as part of the nonpharmacological firstline treatment for low back pain since 2017.  Efforts such as these have been impactful. From 2017 to 2018, there was a 13.5% decrease in the prescription opioid-involved death rate.  In addition, the rate of opioids dispensed in the United States decreased from 72.4 to 46.7 per 100 persons from 2006 to 2019.  Despite progress made, prescription opioids were associated with 28% of opioid-related overdose deaths in 2019. 
Spinal Manipulation Decreases Opioid Use
Systemic reviews and meta-analyses of 26 randomized clinical trials of spinal manipulative therapy (SMT) for acute low back pain and 47 randomized clinical trials of SMT for chronic low back pain found SMT performed by chiropractors, physical therapists, and other providers to be relatively safe and associated with modest improvements in pain and function. [8, 9] However, the most significant benefit of SMT may be its association with decreased opioid use among patients who receive it. In 2020, Whedon et al  demonstrated in a retrospective cohort study of 101,000 patients treated by a chiropractor and a primary care physician for spinal pain had half the risk of filling an opioid prescription compared with patients seen by a primary care physician alone. In 2018, a crosssectional study by Lisi et al  found a reduction in the rate of opioid prescription from 15.9% to 11.5% among 14,025 veterans receiving chiropractic care following their initial chiropractic visit.
The retrospective and cross-sectional designs of these studies and their lack of information regarding the subject’s racial/ethnic background and income level prevent establishing causation and introduce the potential for confounding, respectively. There is an additional limitation for the cross-sectional study regarding generalizability due to the study’s inclusion criteria which required that subjects have at least 1 visit to both Veterans Affairs (VA) primary care and chiropractic services. Last, a recent review and meta-analysis by Corcoran et al  found that patients treated for spinal back pain with chiropractic services had a 64% lower odds of being treated with opioids than patients not seen by a chiropractor. The review and meta-analysis has limitations due to only 6 research articles meeting the inclusion criteria; 5 were retrospective cohort studies. One was a prospective cohort study that defined exposure as back injury and not chiropractic treatment. 
The main limitation of the observational studies mentioned
above, common to many chiropractic services studies
where a randomized control design may not be possible, is
selection bias due to the subject’s self-selection to the chiropractic services group. It is possible that patients who
choose to receive chiropractic care also favor nonpharmacological treatments and are inherently opposed to being treated with opioid medications, independent of receiving chiropractic services. In addition, racial/ethnic and income level are important patient characteristics to consider when interpreting chiropractic research.
In 2006, Davis et al  reported that 92.3% of chiropractic patients were White, and only 3.7% were Black. Last, the retrospective and crosssectional studies mentioned did not report the spinal disease severity of their subjects. Only one of the studies in the review and meta-analysis by Corcoran and colleagues reported the severity of the spinal disease. Therefore, subjects receiving chiropractic services may have had less painful spinal disease than patients treated by primary care providers only.
Insurance Coverage for Spinal Manipulative Therapy
In the United States, most private insurance plans, State
Workers Compensation programs, and Medicare/Medicaid
programs provide reimbursement for chiropractic services.
However, often with exceptions, such as chiropractic services
only being covered to correct spinal subluxation. A crosssectional study of 45 Medicaid, commercial, and Medicare Advantage plans by Heyward and colleagues found that physical therapy was frequently and consistently regarded as medically necessary for low back pain by insurance policies. At the same time, chiropractic services were determined medically necessary for low back pain by 50% of the commercial health insurance policies sampled. The other 50% considered chiropractic services medically necessary only if preconditions were present. 
Further, insurance policies do not cover the evaluation by chiropractors needed to diagnose the required precondition. A potential barrier to insurance coverage for chiropractic services is that some health plans are concerned about liability and malpractice insurance costs associated with chiropractic services. In a review of 48 litigation cases against chiropractors, Hartnett et al  found that 94% of claims following chiropractic care involved SMT. Health care changes are currently being made to promote nonpharmacological treatment for low back pain. For example, under a new UnitedHealthcare policy, patients who see a chiropractor or physical therapist as their first contact provider for low back pain will be billed zero dollars out-of-pocket for their first 3 visits. 
“With millions of Americans experiencing low back pain currently or at some point during their lifetimes, we believe this benefit design is already making a meaningful difference by improving health outcomes and reducing costs, both of which are important amid the coronavirus disease 2019 pandemic and opioid epidemic.” Said Russell Amundson, MD, a neurosurgeon and senior
medical director for UnitedHealthcare (R. Amundson,
personal communication, 2020, written form).
Improving Integration of Chiropractors in the Primary Care Setting
One method for increasing the utilization of SMT is by
increasing provider referrals to chiropractors and improving
collaboration among all treating providers in a team approach.
Referrals are already standard practice with physical therapy,
facilitating communication between referring providers and
physical therapists regarding patient care. For chiropractic
services, the current system relies heavily on patient selfreferral. 
Self-referral limits communication and collaboration between chiropractors and primary care providers and promotes segmented patient care. An additional approach to increasing the utilization of spinal manipulation is to have chiropractors physically located in outpatient medical centers. “Having chiropractors integrated into the primary health team as nonprescribing frontline providers for patients with back
pain will improve health care by decreasing patient dependence
and addiction to opioid medications.” Said Ian Coulter,
RAND Corporation, Senior Health Policy Researcher (I. Coulter, personal communication, 2020, oral and written form).
Outside of the private health care setting, the VA has demonstrated that chiropractors can be integrated into current health systems where there is interest in doing so. Currently, there are over 150 VA health care facilities in the United States offering in-house chiropractic services.  In the private health care setting, a survey of chiropractors found that integrated chiropractors reported more patient referrals and communication regarding shared patient care through direct face-to-face communication and shared electronic medical records than chiropractors in traditional standalone chiropractic practices did. 
Increasing the utilization of spinal manipulation by chiropractors to reduce opioid use among patients with low back pain is a possible strategy to combat the opioid epidemic. Randomized clinical trials of SMT by chiropractors and other providers have demonstrated an association with modest improvement in pain and function in patients with acute and chronic low back pain.
Observational studies have demonstrated a negative association of opioid use among subjects receiving chiropractic services. Experimental studies designed to assess causality should be conducted to strengthen the evidence that SMT by chiropractors decreases opioid use among patients. Such evidence would support the expansion of chiropractic integration including increased referrals, improved collaboration with primary care physicians, and physical integration, as seen in the VA.
In addition, stronger evidence would support the expansion of insurance coverage for chiropractic services and reduction in reimbursement gaps between chiropractic services and physical therapy.
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