If you want to reduce the number of opioid prescriptions and pills being used, and potentially misused, you need alternative pain management. And chiropractors say that’s what they’ve been providing for decades.
“It gives people options, and that’s probably the most important thing right now is to give people options for treatment,” Dr. Mark Stagnone, president of the New Hampshire Chiropractic Association said.
At its annual meeting, the association is pointing to a trio of recent studies showing that chiropractic care cuts down on the use of opiate pain medicines.
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In one of the studies, a former Dartmouth doctor analyzed 33,000 cases of lower back pain in a New Hampshire database.
“His preliminary research is indicating that there’s about a 56-57 percent reduction in opioid use when chiropractic care has been utilized in a patients treatment,” Stagnone said.
James Vara, the governor’s adviser on addiction and behavorial health, said the state needs more alternative pain management.
“It becomes a question of what insurance covers it and how long they cover it for, and that’s certainly something I’ve looked at and will continue to,” said Vara.
The Current Insurance Model Puts Patients On A Path To Prescription Drugs
“The problem that it produces is that the average individual who’s trying to treat a condition is faced with paying a high co-pay to visit a chiropractor or paying a considerably lower one to see a primary care physician,” Stagnone said.
Changing that dynamic will require legislation that has failed in the past. But chiropractors said in this ongoing addiction crisis, it’s time for adjustment.
Chiropractic care is covered under the New Hampshire Health Protection program, or expanded Medicaid. And if the program lapses, so does that coverage.
Painkillers Sometimes Increase Chronic Pain
We’re facing an opioid addiction crisis in America. Opioid (narcotic) pain medications killed an estimated 14,000 people in the U.S. in 2014 through overdose. A further 14,000 people overdosed on heroin, another opioid that many people turn to when they can’t access prescription painkillers.
Opioid painkillers like hydrocodone can trigger dependency and increased sensitivity to pain.
This epidemic is why physicians and pharmacists are increasingly raising the bar on who can receive opioid medications, how much, and for how long. It’s not just the addiction risk that calls for caution when using opioids to treat chronic pain though—long-term use of opioids can actually make pain worse.
Physical Impact Of Painkillers
Becoming addicted to pain medication is a disease. This is because these painkillers (oxycodone, hydrocodone, methadone, fentanyl) cause a change in your brain chemistry that is not under your control.
Most people who take opioids for more than 2 to 4 weeks will develop a tolerance to the medication. Tolerance means your body may need an increased dosage to feel the same effect. Opioid tolerance can cause withdrawal symptoms when the medication is stopped. This is a natural process, and it is not to be confused with addiction.
In his recent blog on the subject, Dr. Ullrich explains: “Pain medication addiction is a more complicated process. It involves manipulative behavior to obtain narcotic medications and a refusal to discontinue a medication even though it is no longer being used for a medical purpose. Some, including those at significant risk of overdosing, will go to multiple doctors to get medications.”
For those who are addicted to opioid medications, a detoxification program is often needed. Painkiller addiction is a chemical, physical disease, one that requires expert medical treatment in a safe, humane environment.
Painkillers May Increase Pain
Most people know that painkillers can be addictive, but they don’t know that taking opioids over a long period of time may in fact increase a patient’s sensitivity to pain (hyperalgesia). This happens because long-term use of opiate painkillers causes a decrease in your ability to tolerate pain and an increase in sensitivity to pain. In fact, people taking opioids long term may keep having pain, or may see their pain increase, long after the original cause of pain has healed.
Stopping opioid use can solve this problem—but it may not seem as if the pain is gone at first, because the discomfort of withdrawal can mimic the original pain. Dependency is not easy to deal with, but it shouldn’t be an excuse to stay on the opioid medication and raise the risk for addiction. This is why physicians are encouraged to only prescribe opioids for short durations and be cautious when using them to treat chronic pain.
Since long-term use of opioid painkillers is a risky option for controlling chronic pain, patients are often advised to focus on other safe, proven methods for managing chronic pain, such as:
- Exercise to maintain motion and release endorphins
- Cognitive therapy to develop coping techniques
- Relaxation and meditation techniques to distract the brain from pain
- Manual (massage) or topical (heat or cold) therapies
- Other pain medications that are lower risk or non-habit forming
An increase in addictions and deaths due to opioids has raised significant concern and media attention. We offer this brief overview on this important public health problem for the practicing chiropractor.
1. What Are Opioids?
Opioid medications are prescribed to reduce pain; however, they are addictive and can be dangerous. Although some suggest there is “no safe dose” for opioids, these drugs may be helpful for people with severe pain, such as those experiencing pain from cancer. However, over the past several decades, more patients have been prescribed opioids for musculoskeletal pain, such as back or neck pain, instead of being provided with nondrug therapies.
As with any drug, opioids have side effects and may “adversely affect respiratory, gastrointestinal, musculoskeletal, cardiovascular, immune, endocrine, and central nervous systems.”1 As the dose increases, the risks for overdose and health concerns also increase, including “fractures, addiction, intestinal blockages, and sedation.”1 If too high a dose is consumed or if opioids are taken with certain other drugs or alcohol, death may result.
2. Why Is Opioid Use / Overuse Problematic?
Since 1999, prescription opioid sales have increased fourfold, along with a surge in the use of opioids as a first line for pain management, rather than only for severe cancer-related pain. This trend has led to burgeoning opioid prescribing in the U.S.:2
- One in five people with non-cancer pain have been prescribed opioids.
- More than 165,000 prescription opioid-related deaths occurred between 1999 and 2014.
- An estimated 2 million people were addicted to opioids as of 2014.
3. Who Is Addressing This Health Crisis?
Currently, many professions are seeking ways to address this national epidemic. The medical profession has launched various initiatives to help medical doctors (MDs) reduce prescriptions. These include an initiative to remove pain as the 5th vital sign, and promoting guidelines for when to prescribe and how to better manage patients in pain without the use of opioids.
The Centers for Disease Control and Prevention (CDC) has released guidelines to curb opioid prescriptions, with the following categories of recommendations to those who prescribe opioids: 1) determine when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, discontinuation, and assessing risk; and 3) addressing harms of opioid use.
In addition to these efforts, even more focus is needed to assist people who seek help for pain and to provide them with nonpharmacological alternatives.
4. What Can Doctors of Chiropractic Do?
Chiropractic care can be part of the solution. DCs can work with other health care providers and support policy to offer alternatives to opioids for addressing patients in pain, especially chronic non-cancer pain.
Although there are no large trials comparing outcomes of chiropractic care to opioids, we do know opioid use is associated with worse functioning in back pain patients at six-month follow-up3 and greater disability;4 and that injured workers whose first health care visit is to a DC have better outcomes.5 We also know that the per-capita supply of DCs and higher use of manipulative therapy is associated with lower rates of opioid prescriptions among Medicare recipients.6
All this suggests chiropractic care may help reduce the use of and need for opioid prescriptions for back pain sufferers; and may play an important role in reducing the opioid epidemic by helping to prevent patients from ever getting an opioid prescription in the first place.
Important resources DCs should be aware of include:
- Never Only Opioids: www.painsproject.org/ policy-brief-never-opioids/
- Chiropractic: A Safer Strategy Than Opioids: www.f4cp. com/f4cp_opioid_white_paper.pdf
- Centers for Disease Control and Prevention (CDC): Opioid Overdose: www.cdc.gov/drugoverdose/ Six Things Every Chiropractor Should Know About Opioids By Claire Johnson, DC, MSEd, PhD, Bart N. Green, DC, MSEd, PhD and Michael Haneline, DC, MPH Reprinted with permission from Dynamic Chiropractic, Sept. 1, 2016, Vol. 34, Issue 15 (www.dynamicchiropractic.com/digital/index.php?i=1220&r=t#19)
5. What Can We Do If a Patient Is Already Taking Opioids?
Most chiropractors take a history and ask patients what medications they are taking. The first step is to recognize that the following are opioid-class drugs: hydrocodone (Vicodin), ultram (Tramadol), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza) and codeine.7
Once we know a patient is taking opioids, we must first seek to understand the situation before we provide education.
Questions we can ask include:
- For what condition is the patient taking the medication?
- How long has the patient been taking opioids and at what daily dose?
- Who is the provider watching over their prescription? Is more than one provider prescribing opioids?
- When was the last time the patient saw the prescribing physician and when is the next appointment?
- Does the patient have any safety issues? For example, does the patient operate machinery? Is the patient experiencing side effects such as “sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, or respiratory depression”?8
- What is the patient’s level of function? Are there any psychological flags or addictive behaviors?
- Is the patient taking any other substances or drugs that may have deadly interactions, such as alcohol, benzodiazepines and/or other opioids?
As chiropractors, we can discuss treatment goals, such as reasonable functional activity; and pain goals with and without medication. We also can discuss potential adverse events, including the risks for side effects, addiction and death.
We can inform patients of other dangers they may not be aware of, such as the deadly combination of opioids when combined with other drugs that depress CNS activity (e.g., alcohol or drugs for anxiety such as benzodiazepines). We can encourage patients to contact the prescribing provider to discuss reducing and stopping opioid use, and to ask for safer alternatives for pain control, such as chiropractic care, physical therapy, acupuncture and mind-body methods. If a patient is already addicted, we can encourage the patient to seek a specialist provider and addiction care program. (Note that some patients may need to remain on opioids, such as for cancer pain or end-of-life care.)
Most importantly, we can work with the patient and their prescribing provider to offer them nonpharmacological care to help reduce their pain and help them reach their functional goals.
6. How Can We Collaborate More on Solutions?
As DCs, we can work more closely with local MDs and discuss better ways to collaborate concerning patients with pain. Remember that MDs are not the enemy, but are an essential component of the solution to this epidemic. Most MDs are also extremely concerned about the opioid epidemic, and are looking for efficient and cost-effective ways of helping their patients. We should remain professional when speaking about MDs with our patients, as our patients likely have good relations with them.
We can be part of the safety net to help reduce the number of people who become addicted or die from overdose. As we work with other health care professionals and our patients, we can remind them that the first recommendation per the CDC’s Guideline for Prescribing Opioids for Chronic Pain is “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.”9 Thus, through collaboration, the chiropractic profession can be a part of the solution.
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