Does chiropractic care reduce opioid use?

Whether your painful complaint consists mainly of back, neck shoulder or even hip pain, for many non-chiropractic practitioners drugs, usually painkillers are the first weapon of choice when it comes to treatment. While short term use of common medicines such as Ibruprofen may provide relief and come at a fairly low risk, far too many patients end up relying on more dangerous drugs such as opioids in the long term. New research now suggests that chiropractic care reduces this risk.

 

Treating pain with medication

When you’ve suffered an injury or are struggling with nonspecific pain (pain which does not have an obvious source or cause) its understandable that your first reaction is to try to lessen the pain. In an ideal world, a visit to the chiropractor right away is the best move, but for many of us that isn’t always practical. For this reason short term use of medication might be an acceptable compromise – not great for you, but it will get you through the day. Under no circumstances, however, should you view painkillers as a long term treatment for pain – pain is your body telling you that something isn’t right, and its that thing, not the pain, which needs to be addressed!

In fact, it is also far from clear that medication really is a positive approach in anything but the very short term. Paracetamol, our cheap and widely available “go-to” drug was once the preferred medicine for non-specific low back pain based on the view that it was cheap, safe and effective. While paracetamol might be cheap (and safe in the short term) we now know that it actually isn’t effective. Aa systematic review including three randomised controlled trials concluded there was high-quality evidence that paracetamol was no more effective than placebo for acute non-specific low back pain.[1]

A second common option are Non-steroidal anti-inflammatory drugs or NSAIDs. Unlike paracetamol, evidence shows that NSAIDs can have a positive effect in the short term– A systematic review including 35 randomised trials found moderate-quality to high-quality evidence that NSAIDs reduce acute non-specific low back pain by about 6 points, and chronic non-specific low back pain by about 11 points, on a 100-point scale.[2] If you’re going to reach for a short term stop-gap, Ibuprofen or something similar might be the way to go.  Having said this, it’s also true that 11 points on a 100 point scale is not very much, and there are some known risks associated with long term consumption – some studies have shown evidence that NSAIDs may slightly increase the risk of heart problems, and it is well known that they carry gastrointestinal and renal risks.

Another, stronger option – and the one which concerns most of us in the field today – are opioids. In 2014, nearly half of the prescriptions that Australian general practitioners provided for non-specific low back pain were for opioid or opioid combinations, and approximately 3%–4% of the US population receive long-term opioid therapy!  Despite this, there have been no randomised placebo-controlled which have properly investigated opioids for acute non-specific low back pain. Why you ask? In fact, more than half of patients cannot even tolerate opioids and remain well enough to stay in a trial – let alone rely on them as a long term solution.[3] In the US, The National Survey on Drug Use and Health reported over 42,000 prescription opioid-related deaths in 2016, with total estimated costs of prescription opioid use reaching US $78.5 billion[4] – clearly, opioids present a health risk in and of themselves.

 

Chiropractic – a better option!

From the above its clear to see that the majority of commonly used medications either don’t work, or come with some substantial risks when it comes to managing pain. While a short term stop gap might be necessary to get you thought the day, it should only ever be a short term crutch while you wait to get to the chiropractor!  We have long argued that the chiropractic approach is a far better choice in terms of speed of recovery and pain reduction, but new research has now also suggested that chiropractic care can reduce the use of opioid medication in pain patients quickly, therefore reducing the risks associated with long term use.

The 2018 study[5] looked at the case history of over 216,504 patients who sought treatment for a painful musculoskeletal condition.  Of these, more than half (53%) visited a non-medical care provider as the first line of treatment, and of those, the most popular options were a chiropractor (23.1%) followed by a physical therapist (1.6%) and an acupuncturist (0.8%).

Based on patterns of treatment, te study investigators worked out the relationship between the treatment that these patients received and their likelihood of opioid use. In all cases, treatment from a professional in manual therapy reduced the risk substantially – For early opioid use, patients initially visiting chiropractors had 90% decreased odds while those visiting acupuncturists had 91% decreased odds and those visiting physical therapists had 85% decreased odds. Chiropractors, acupuncturists and physical therapists all also had major decreased odds of long-term opioid use compared with those who initially saw a medical professional.

While correlation does not necessarily mean causation, the authors speculated that there are several important reasons for this lower risk. Firstly, since non-physicians are unable to prescribe opioids, patients seeking conservative therapy are unable to be given opioid medication at their initial visit – while this is to case aspersions neither on conservative therapists nor medical professionals, it is perhaps helpful that the option to “just give them pills” does not exist. S

Secondly, it was speculated that there may be selection bias among patients choosing to seek initial treatment from conservative therapists, and such biases could be related to educational level or preferences which may also result in a decreased desire for those patients to use opioids.

Finally, the authors acknowledged that the conservative therapy provided may indeed result, on average,  insufficiently decreased pain and improved back-related function so that patients do not need or seek opioid medications. Indeed, today a growing body of high-quality evidence does suggest that spinal manipulation, massage, acupuncture and superficial heat are effective for reducing acute back pain intensity and improving function.[6]

 

So what’s the takeaway here?

The point of this article isn’t to say that medication is all bad and should be avoided – but we do want to stress that any medication comes with risks and that often when it comes to spinal pain, medication won’t make a huge difference but may cause long term problems. If you’re in pain right now, an NSAID such as ibuprofen may be an effective short term way to manage your discomfort, but your very next move should be to book an appointment with the chiropractor!

 

 

 

[1] Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis

[2] Abdel Shaheed C, Maher CG, Williams KA, et al. Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA Intern Med 2016;176:958–68.

[3] Abdel Shaheed C, Maher CG, Williams KA, et al. Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA Intern Med 2016;176:958–68

[4] Opioid Overdose [Internet].

Centers for disease control and prevention. centers for disease control and prevention, 2017.

Available:

[5] Lewis E Kazis, Omid Ameli, James Rothendler, Brigid Garrity, Howard Cabral, Christine McDonough, et. al. 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

[6] Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline Annals of Internal Medicine 2017 (Apr 4); 166 (7): 493–505

Jackknife and bootstrap analyses, 2010. Available: http://support.sas.com/kb/24/982.html

Chou R, Huffman LH; American Pain Society. Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/ American College of Physicians Clinical Practice Guideline Annals of Internal Medicine 2007 (Oct 2); 147 (7): 492–504

Blog by / September 27, 2019 / Blog

Dr Paul Irvine
Dr. Paul Irvine is a doctor of chiropractic who graduated in 1994 with a Bachelor of Science degree from the University of NSW and in 1996, attained his Master of Chiropractic degree from Macquarie University in Australia. He practised in North Sydney for 5 years before he left Australia to travel and practise in the UK. He joined Complete Chiropractic in 2003 (est 1999) and took over the clinic in 2007