Welcome back to SpineIQ’s Back Blog! During the month of October, we will be highlighting some studies or people that won awards at the most recent World Federation of Chiropractic conference! This week, we will discuss “Impact of Chiropractic care on use of prescription opioids in patients with spinal pain” by Whedon et al¹, that won the Scott Haldeman award for Outstanding Research! This study is important because it attempts to shed some light on the role that conservative spine clinicians can have in the opioid crisis! Undoubtedly the entire nation is aware of and has heard about, read about or seen on Television a story about the devastation opioid’s cause whether prescribed or illegally obtained.  As with all societal changes they are very difficult to implement rapidly. The consideration of non-pharmaceutical approaches is undoubtedly one of those paradigm shifts which will take time.  Well conducted and constructed research is critical to advancing those changes.

Purpose of the study

Unfortunately, drug overdose deaths continue to increase in the US with recent data showing an increase by 10% from 2016 to 2017², many of these deaths associated with opioid usage.³ Clinical practice guidelines have recommended that nonpharmacological treatment is used prior to opioid prescription for low back pain.⁴ However, 59% of opioids prescribed in the US are for low back pain.³ This study attempted to study how chiropractic care was associated with opioid usage in three northeast states.

Methods
The researchers used claims data from Connecticut, Massachusetts, and New Hampshire in their analysis. Included participants were adults (>18) with at least two visits to a healthcare provider for spinal pain within 90 days. Participants that received primary care and chiropractic care were compared to participants that only received primary care. Additionally, the researchers did a secondary analysis comparing participants that received chiropractic care within 30 days of their initial visit compared to the rest of the participants.

Results

Participants that did not receive chiropractic care at all was associated with an increased risk of opioid usage which varied by state (55% Connecticut, 103% New Hampshire, 73% Massachusetts). Additionally, participants that did not receive chiropractic care within 30 days of initial visit were associated with increased risk by 68% to 92% compared to participants receiving chiropractic care within 30 days of initial visit.

Conclusion

This study adds to a growing evidence based that suggests conservative spinal care is associated with decreased risk of opioid prescription and usage.^5,6 Considering the impact that the opioid crisis has had in the US and elsewhere, clinical care pathways where patients receive treatment from conservative spine clinicians quickly when they seek care must be properly implemented and evaluated. It is important to remember that this study is a retrospective cohort study so causality can not be assumed. Future research that prospectively randomizes patients to receiving care from spinal care clinicians are needed to assess whether the decreased opioid usage is due to the provider. While many practicing clinicians recognize that patients receiving conservative care tolerate pain better and utilize less drugs, are facts, concepts and theories  which must be validated in research trials which will prospectively answer specific questions which are now simply assumptions. The fact that the opioid crisis has reached a virtual tsunami of concern, with each research project that validates the effectiveness of a chiropractic non-pharmaceutical approach could not be better timed.

References:

1. Whedon JM, Toler AWJ, Kazal LA, Bezdjian S, Goehl JM, Greenstein J. Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain. Pain Med Malden Mass. 2020;21(12):3567-3573. doi:10.1093/pm/pnaa014
2. Substance Abuse and Mental Health Services Administration (US), Office of the Surgeon General (US). Facing Addiction in America: The Surgeon General’s Spotlight on Opioids. US Department of Health and Human Services; 2018. Accessed October 5, 2021. http://www.ncbi.nlm.nih.gov/books/NBK538436/
3. Hudson TJ, Edlund MJ, Steffick DE, Tripathi SP, Sullivan MD. Epidemiology of regular prescribed opioid use: results from a national, population-based survey. J Pain Symptom Manage. 2008;36(3):280-288. doi:10.1016/j.jpainsymman.2007.10.003
4. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
5. Weeks WB, Pike J, Donath J, Fiacco P, Justice BD. Conservative Spine Care Pathway Implementation Is Associated with Reduced Health Care Expenditures in a Controlled, Before-After Observational Study. J Gen Intern Med. 2019;34(8):1381-1382. doi:10.1007/s11606-019-04942-7
6. Weeks WB, Goertz CM. Cross-sectional analysis of per capita supply of doctors of chiropractic and opioid use in younger Medicare beneficiaries. J Manipulative Physiol Ther. 2016;39(4):263-266. doi:10.1016/j.jmpt.2016.02.016