In chiropractic circles, we love drug-free, surgery-free healthcare. We realise such things can’t always be avoided, which is why subluxation-based care is a centrepiece to the chiropractic profession and why we nurture the nervous system for the expression of health and life. However, given the topic of opioid overuse and addiction that has been in the media recently, it is apparent that we need to address this in chiropractic circles. We are going to discuss, in this blog, opioid use, and the potential role of chiropractic.
The opioid crisis is particularly prevalent in America, evidencing its impact on the health and lives of those living with chronic pain. Here’s what we know from the literature so far [1, 2]:
- Opioids are commonly prescribed to provide temporary pain relief.
- They are not always effective and have been associated with addictions, overdose and in extreme cases, even death.
- There was a total of 30,843 apparent opioid-related deaths and 32,319 opioid-related in Canada between January 2016 and March 2022. In the United States (US), there were approximately 60 000 opioid-related deaths in 2016 alone.
- Typically, young adult men are most affected by the opioid crisis.
While no single contributing factor can be a panacea for this complex issue, as addiction is indeed a many-faceted disease in and of itself, we love reading new research on how chiropractic care may reduce dependence on or need for opioid medication. The latest piece of this research emerges from Canada.
The current study was a mixed method analysis, including both quantitative and qualitative data in the report . While quantitative information – results you can quantify – provide easily comparable objective findings, it can be reductive. Qualitative results can provide more detailed answers to research questions. This can be particularly important for interventions like chiropractic, which takes into consideration an individual’s lifestyles as a whole and attempts to identify and care for the individual as a whole and just not the symptoms in isolation.
We have previously covered mixed methodology and the need for more mixed methodologists included on research teams. You can read more about that here.
The researchers of this study were investigating the association between receiving chiropractic care and opioid prescriptions in an adult population. The sample was taken from a primary health care centre and included adults who had presented with back or neck pain (not associated with cancer) within a 7-year period. Patients were excluded for a number of criteria, such as an arthritis diagnosis, to produce a smaller and more uniform sample. The researchers were expecting to see chiropractic care inversely associated with receiving opioid prescriptions, that is, when the measure of chiropractic care increases, opioid prescriptions decrease and vice versa. They also expected that patients younger in age, of male sex, presenting with comorbid depression, anxiety, fibromyalgia, diabetes, or cardiovascular disease, obese, with a positive smoking status, or a higher frequency of health care and earlier visits would be positive associated with opioid prescriptions.
The main outcome the researchers where measuring was the length of time to a patient’s first opioid prescription. After the quantitative data was collected a subsample of patients were interviewed. The researchers chose individual interviews instead of conducting focus groups as the research topic was sensitive in nature and wanted patients to feel comfortable sharing their perspective fully without the presence of other patients. The interview subsample was stratified, meaning the original larger sample of patients were characterised into groups and members from each strata were taken to form the subsample. This is often done in research to ensure the subsample remains representative of the original sample.
This study was investigating whether there was a correlation between receiving chiropractic care and receiving a prescription for opioids for the relief of noncancer spinal pain? This is what they found:
- 51% of patients that did not receive chiropractic care received an opioid prescription (at 1 year)
- 29% of patients who received chiropractic care received an opioid prescription (at 1 year)
- 52% lower risk of receiving an opioid prescription in patients receiving chiropractic care compared to those who were not.
- Risk of receiving an opioid prescription was 71% lower in patients who received chiropractic services within 30 days of their initial visit.
- Higher frequency of healthcare visits, older age, positive smoking status, and depression were positively associated with receipt of opioids.
Researchers identified the risk of receiving an opioid prescription associated with a positive smoking status and comorbid depression were increased by 62% and 77% respectively.
The decreased risk of an opioid prescription associated with receiving chiropractic care led researchers to suggest those patients referred for chiropractic care by their practitioner may have been more resistant to taking opioids. This may require further investigation, as it may be the philosophical standpoint of the patient, the educative effect of the chiropractor or other factors at play that create this effect. This is as yet undefined. The findings also suggest that when chiropractic care is accessed as a first-line treatment option, prescription of opioids are delayed and potentially prevented.
It is not surprising that those patients whose initial visit occurred more recently were less likely to receive a prescription for opioids. This may be in part due to the growing awareness of the opioid crisis, and the devastating effects of overprescription of and dependence on opioids or it may also be that people receiving chiropractic care have a different philosophical standpoint. It could also be that chiropractic care reduces their subjective levels of pain and therefore their perceived need for medication. Further research and investigation into this would be beneficial.
Twenty-three interviews were completed consisting of 14 patients and 9 general practitioner or nurse practitioner interviews. From those interviews, a lack of access to non-pharmacological services, such as chiropractic or physical therapy, was identified by all participants. It was reported by both patients and practitioners as a common facilitator of opioid use. Some patients expressed a sense of judgement from others for taking opioids for pain relief and finding it frustrating to be treated like an addict. One patient in the study remarked that :
“It’s been frustrating—so frustrating. Because the [opioid] crisis seemed to just fall right on me. Like, as though I’m part of the crisis. So, [as a result] every doctor doesn’t want you on any kind of pain medication. They don’t believe your pain. You know what I mean? It has really affected me. …I’m not an addict in any way. I never even ever think twice about taking that medication more than once, like, unprescribed. But I was definitely treated like I was [an addict].”
While this study is incredibility enlightening, it is retrospective in design and as such has inherent limitations. The researchers acknowledged that certain variables that may have been important to consider, such as baseline spine-related pain or additional interventions patients were receiving outside of the study were unavailable and thus not included. Similarly, no social determinants of health could be included in the present study and may have influenced patient outcomes.
The ‘time to prescription’ measure utilised by the researchers acts as a substitute for more patient-centred outcomes, such as pain reduction or functional improvement. We also acknowledge that recipients of chiropractic care may have been prognostically different from nonrecipients despite adjustments for confounding variables. We also acknowledge that observational research is prone to selection bias and RCT’s are needed to confirm or oppose these findings.
When we consider the opioid crisis, we need to ask ourselves, and practitioners need to ask their patients, whether or not the focus is on removing interference to the body’s natural healing process and allowing the body to move in the direction of self-healing, self-organisation and self-regulation. If there is a philosophical basis of patients to rely on their body’s own healing potential, then chiropractic may offer an incredible opportunity to reduce the reliance on opioids, thereby improving people’s quality of life and reducing the risk factors associated with taking opioids – this surely can only be viewed as a good thing?
- Opioid- and Stimulant-related Harms in Canada [Internet]. Government of Canada. 2022. Available from: https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/
- Rummans TA, Burton MC, Dawson NL. How good intentions contributed to bad outcomes: the opioid crisis. Mayo Clin Proc. 2018;93(3):344-350.
- Emary PC, Brown AL, Oremus M, Mbuagbaw L, Cameron DF, DiDonato J, et al. Association of Chiropractic Care With Receiving an Opioid Prescription for Noncancer Spinal Pain Within a Canadian Community Health Center: A Mixed Methods Analysis. Journal of Manipulative and Physiological Therapeutics. 2022. 45(4):235–47.