The opioid crisis has been a topic of concern for health practitioners for a number of years now. While the USA is the most affected country with 70% of all overdose deaths in 2018 involving opioids, many of the same issues exist in Australia and other countries, prompting calls for proactive intervention from health professionals. What then is the chiropractic role in this? Two papers have dropped over at the Chiropractic Journal of Australia, tackling this very important topic. Here’s the scoop.
Opioid’s effectiveness in treating a variety of chronic pain conditions, as well as acute pain and cancer pain, has seen the clinical use of this class of drugs become quite widespread. But as much as they can be effective with pain, opioids can also have many negative effects. While the list of potential side effects is large, the short version is this: overexposure to opioids can have significant effects on mood, pain perception, concentration, cognition, physiological homeostasis, hormone regulation, and addiction.
But how does an opioid crisis come about? The authors of the recently published papers point out that it is the result of complex interplay between non-medical use, overexposure, overprescription, and misinformation. “The clinical message is that pharmaceutical opioids need to be avoided where possible and, when used, appropriately and judiciously prescribed and used by patients in a responsible manner to maximise their benefits and lessen the risks of harm .”
As chiropractors, we are uniquely placed to empower patients with non-pharmaceutical choices when it comes to pain management. For example, when treating patients with non-cancer spinal pain, there is a crucial role for a practitioner to provide education about evidence-based management of pain to lessen the risk of overexposure to opioid medication. It is simply not that well understood that medication is not the only answer to the pain problem.
Is it an important issue for Australian chiropractors as well as American and other chiropractors? The paper presents a persuasive case for the answer to be a firm “Yes”
The Australian Picture:
Australia currently ranks 8th of 30 developed countries for the use of prescription opioids. Here are some important findings from the Australian Institute of Health and Welfare:
- 3.1 million people had 1 or more prescriptions dispensed for opioids (most commonly for Oxycodone), and about 715,000 people have used pharmaceutical opioids for illicit or non-medical purposes;
- Pharmaceutical opioids are responsible for far more deaths and poisoning hospitalisations than illegal opioids, such as heroin. Every day in Australia, nearly 150 hospitalisations and 3 people die from drug-induced deaths involving opioid use;
- The rate of poisoning, hospitalisation and deaths from opioids from 2007-2017 increased by 25%, 36% and 63%, respectively; and
- Of people who reported non-medical use of pharmaceutical opioids, 75% had used over-the-counter (OTC) codeine-containing products, 40% had used prescription codeine-containing products, and 17% had used Oxycodone.
At present, opioids account for 70% of adverse health consequences associated with drug misuse disorders across developed countries. World Health Organization data shows 69,000 people worldwide die from opioid overdose each year. Most of these are in the USA and Canada. Some of these prescriptions were for palliative care or acute pain which impacts the validity of the data only slightly. Many more of these prescriptions were for chronic non-cancer pain including backache, headache, or fibromyalgia.
“Expressed succinctly; there has been a significant escalation in prescribing and use of pharmaceutical opioids over the past two decades across western nations; overuse and misuse of pharmaceutical opioids are associated with considerable morbidity, hospitalisations and overdoses–including problems with toxicity, addiction, falls (with injury) and traffic accidents (27-29). Prescriptions for pharmaceutical opioids are often not concordant with clinical guidelines, where the risks of use often outweigh the benefits; and opioids are relatively easy to access with – or without a prescription, including black-market access.”
The papers, authored by Shobbrook, Amorin-Woods and Parkin-Smith, including some compelling data-points that indicate chiropractic has a role in reducing problematic opioid usage. These included the following :
- “Where chiropractic is offered in the military system, 59% of patients reported a reduction in narcotic painkillers use.”
- “For those patients with pain scores by modality, the largest portion (between 32-100%) had unchanged pain scores, with the exceptions of chiropractic, massage, recreational therapy, superficial heat, and ultrasonography, where veterans experienced a decrease in pain scores.”
- “Nearly one-third of veterans receiving chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower after the index chiropractic visit than before.” (This appears to hint at slower usage of opioid drugs).
- “Initial visits to chiropractors or physical therapists were associated with substantially decreased early and long-term use of opioids”;
- “A recent systematic review/meta-analysis found in a random-effects analysis that chiropractic users had 64% lower odds of receiving an opioid prescription than nonusers.”
The Australian Government has initiated plans to tackle the misuse of opioids. Some key strategies include moving opioid products including codeine-containing products from over-the-counter access to prescription only, implementing drug monitoring programs, and allowing access to multi-disciplinary teams in order to improve outcomes for people with chronic pain. These are all positive strategies, but they are newly rolled out and currently lack the funding to tackle the magnitude of the problem. According to the data put forward in these papers, the hidden gem could indeed be manual therapists, and among them, chiropractors (of course).
The authors of the papers remarked, “Best available evidence shows that manual care interventions are likely to reduce pain and improve function for patients with chronic low back pain, whereas medications are not.”
As back pain is understood to be the most common cause of pain and disability worldwide, and remains a challenge to manage, the papers encourage chiropractors to continue to engage strongly in this space.
“The problem may not lie with access to opioids per se, but rather that the patient misses out on the personalised pain care approach and tailored use of opioids. For example, the SPACE trial (2018) demonstrated no advantage for opioid over nonopioid medications for back pain, but the study’s qualitative findings suggested that pre-existing expectations and anticipated improvement in pain shaped experiences with, and responses to, medications.”
If the indications are that opioids provide no advantage over non-opioid medications for back pain, then what is going wrong with opioid usage? There appear to be very basic reasons for non-adherence to medical guidelines for opioid use. They include access to suitable therapies, time limitations and training levels when it comes to health professionals, and perhaps most tellingly misconceptions about pain management both in terms of practitioners and patients.
What do we need to do in order to help mitigate the crisis?
Apart from the obvious – that chiropractors can provide drug-free care to chronic pain patients – there are some clear contributions that chiropractors can make towards reducing the impact of the opioid crisis. We can help change ideas about pain.
The authors of the paper remarked that chiropractors could “promote a non-drug, non-surgical approach to back pain, neck pain and other musculoskeletal disorders; manual therapies, including chiropractic, should be first-line options for the management of musculoskeletal conditions .”
Other action steps included facilitating access to more conservative care options, engaging proactively in patient education and health promotion, and partnering with other health care professionals in order to collaborate in an evidence-based way. The authors also emphasized the importance of expanding knowledge and management skills when it comes to acute and chronic pain, as well as being on top of current evidence and clinical guidelines.
We know that many chiropractors are doing a fantastic job of nurturing, educating and caring for their practice members, so this paper comes as an impetus to carry on the good work in many ways. One recommendation stands out above the rest though: the authors emphasized the importance of supporting research through donations and participation.
In a time where research is currency and is so persuasive when it comes to regulators, governments and policy makers as well as the users of manual therapies and indeed chiropractic care, it is vitally important that we keep advancing the understanding of what chiropractic is and does.
We know what we have works for back and neck pain. We are viewing what is perhaps just the tip of the iceberg when it comes to the non-musculoskeletal and brain-based effects of chiropractic care as research continues to unearth possibilities. We have been able to fund and disseminate research along these lines because of our Foundation’s supporters.
It appears now is a time where we very much need to continue that wonderful work.
- Mitigating the Opioid Crisis: an Australian Perspective on the Role of Chiropractors (Part I). Chiropractic Journal of Australia. 2020; 47(1)
- Chiropractic and the Opioid Epidemic – Strategies to Mitigate Harm and Promote Evidence-based Care (Part 2: Summary). Chiropractic Journal of Australia. 2020; 47(1)