Spine Care Paradigm Shift?

I would venture to guess that most people have at least heard that the U.S. is in a state of crisis regarding the over-utilization of opioids. Chiropractors are not necessarily experts in the field of pharmacology or pharmacodynamics but as I understand it, opioids or opiates are drugs that basically block your brain from perceiving pain messages that come from your body. They are part of a class of substances that includes heroin and cocaine which are derived from the poppy plant and are highly addictive.  

In a letter to the American Health Insurance Plans, the National Association of Attorneys General (NAAG) writes, “The opioid epidemic is the preeminent public health crisis of our time.”  To demonstrate the magnitude of the problem:  about 5% of the world’s population resides in the United States yet we consume over 80% of all the opioids consumed worldwide.  So big deal what does that mean?  Well what most people probably don’t know is that 75% of the heroin overdoses in the U.S. actually started in a physician’s office for the care of chronic pain. The NAAG go on to say that “opioid overdoses kill 91 Americans every single day.  More than half of those deaths involve prescription opioids”.   

This is not really surprising when you look at Alabama’s overall health statistics, but Blue Cross and Blue Shield’s “Health of the Nation” report identifies Alabama as leading the nation in opioid over-utilization statistics.  In one of my recent chiropractic advisory committee meetings with Blue Cross Blue Shield of Alabama, we talked with Axial Healthcare.   Axial Healthcare, who Blue Cross Blue Shield of Alabama has hired to help with the opioid crisis, reports that back pain is the number one chronic pain syndrome for which opioids are commonly prescribed.   Neck pain and other musculoskeletal complaints come in second.  And this despite evidence that opioids while sometimes appropriate (cancer and post surgical pain) are often ineffective and dangerous.  The NAAG letter urges doctors to utilize proven alternative pain treatments such as chiropractic care rather than pharmacology.  

Well that is great for the chiropractic profession, but it goes even further.  Based on an exhaustive literature review of randomized controlled trials the American College of Physicians released new back pain guidelines in February of 2017.  These recommendations modify their 2014 findings and now strongly recommend that doctors no longer use pharmacology (prescriptions medications) as a first line treatment for back pain. Rather, they strongly recommend that proven alternative pain treatments be used and specifically listed spinal manipulation, the primary treatment of chiropractors.  In October, 2017 NBC WVTM asked me to discuss the new guidelines and how they change the landscape of spine care.    

                        NBC WVTM : Chiropractor discusses alternatives to opioids in back pain treatment

The take home message is clear:  Conservative treatments first.  The algorithm for (non-complicated) back pain and neck pain should start on the bottom rung of the ladder.  This rung includes proven, cost efficient, and conservative treatment options like spinal manipulation.  One should only move up the ladder as you fail the more conservative treatments.