Canada-wide, over 2000 people die from opioid overuse (that’s 50% of all annual drug-related deaths) In Ontario, there was a 242% increase from 1991 to 2011 of opioid-related deaths. These numbers parallel the increase in opioid prescriptions over a similar time period.
So there’s a problem. But what does it have to do with chiropractors? We don’t even have prescription rights in Canada. Well, the Canadian Chiropractic Association (CCA) has released a 17-page document in response to Canada’s opioid crisis. The document is well worth a read. If you so desire, you can find it here: https://www.chiropractic.ca/wp-content/uploads/2016/11/A-Better-Approach-to-Pain-Management-in-Canada3-1.pdf. However, if you can’t be bothered, or simply don’t have the time, I’ll do my best to highlight the issue and summarize the profession’s position on the issue. To start with, a little background:
Opioids are a group of narcotic pain medications. They are often prescribed by medical doctors to combat moderate or severe pain that is resistant to less potent medications. Opioids can be an extract from the opium poppy, an extract that has been chemically modified, or they can be entirely manmade compounds that function like naturally derived opiates.
When administered, opioids bind to one of four types of opiate receptors in the brain and spinal cord. Once stimulated, these receptors reduce the transmission of pain signals from the body to the brain without eliminating the cause of the pain. Opioids cause feelings of euphoria, and cause sleepiness and respiratory depression (they slow your rate of breathing). The main danger associated with opioid use is respiratory depression. Even more dangerous is when opioids are combined with other drugs, which have similar effects, such as alcohol and sleeping pills. The pain-relief from opioid use may wear off before the respiratory depression has, meaning people may take more of the drug or feel it is safe to consume alcohol, anti-anxiety pills, sleeping pills, etc., leading to potential overdose.
So, what does this have to with chiropractors, again? Well, back pain and other musculoskeletal (MSK) pain are a leading reason for opioid prescription. Other approaches, such as spinal manipulation, are effective in treating many types of back pain. However, manual therapy, and other conservative care options are often not covered by the publicly funded system, leaving the burden on the patient, making access a challenge for many people. Therefore, physicians may not feel they have many options to consider when it comes to a patient’s pain management – particularly in under-privileged populations.
The CCA believes a broader approach is needed to effectively manage pain. This approach must take into account best practices, and allow for greater access to conservative care. The evidence is clear that chiropractic care, and other manual therapies are effective first-line options for MSK conditions. This is important because the majority of individuals who become addicted after receiving opioid prescriptions were not seeking opioids to manage an existing substance abuse problem; rather they were looking for a means to manage their pain.
Chiropractors are trained to assess, diagnose, and manage a variety of MSK conditions. We use a number of tools to help us achieve our outcomes; chief among them is spinal manipulation (an adjustment), when appropriate. The literature supports the use of spinal manipulation for acute, sub-acute, and chronic low back pain. It helps to reduce pain, and improve function. There are numerous prominent publications, which tout the benefits of spinal manipulation including guidelines issued by the American College of Physicians, the U.S. Department of Veteran Affairs, the Bone and Joint Decade Task Force, the American Pain Society, and Britain’s National Institute of Health and Care Excellence.
Few of our colleagues use manipulation as a standalone treatment option – often it is combined with other manual therapies, modalities, and exercise therapy. Used in conjunction with these other therapies, the results are comparable to the use of prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for short and long-term pain relief, albeit with fewer health risks. It’s important to note that opioids certainly have a role to play when deemed clinically appropriate (they are particularly effective in managing pain caused by cancer), but they are by no means the sole option available.
In order to help individuals suffering from mechanical pain, they need better access to conservative care options. There have been some outstanding examples of the successful outcomes associated with integrating chiropractors into interprofessional healthcare teams to manage MSK-related pain. Chiropractors (and advanced practice physiotherapists) have been used to triage patients as part of a pilot program funded by the Government of Ontario. Early results show a reduction in the use of expensive imaging, specialist referrals, and opioid use, while improving patient function and mobility.
St. Michael’s Hospital in Toronto utilizes a Family Health Team integrative healthcare model, which uses medical doctors, nurse practitioners, nurses, and chiropractors to address MSK conditions. There is now a waiting list for MSK assessments due to the success of the program.
At the Mount Carmel Clinic, in Winnipeg, an inner-city community receives chiropractic services funded by the province of Manitoba. Early results show a significant reduction in MSK pain and improved function for the patients being referred to this program.
The above examples are just three of the promising programs involving multidisciplinary care, and a true patient centered model of care. However, more needs to be done to provide all patients with access to safe and effective care. The CCA has four key recommendations that they believe could reduce the reliance on opioids and lead to major improvements in MSK pain of Canadians. These are as follows:
1. “Collaborate with governments and other stakeholders to support and facilitate innovative practices to improve the delivery of alternatives in primary care.” Essentially, they hope to continue to promote evidence-informed guidance for prescribing professions (physicians, specialists, etc.) on appropriate referral for chiropractic care, and by highlighting the fact that chiropractic care is an important and viable alternative to opioids for back pain and many other MSK conditions.
2. “Ensure and expand access to alternative approaches to opioids such as conservative care modalities for all, but in particular for vulnerable populations. These approaches must be readily available through interprofessional care teams for those suffering from MSK conditions.” The people most affected by opioid misuse are vulnerable populations. The CCA recommends that current models of care be expanded, and new ones explored, that include conservative care options provided by community-based providers, such as chiropractors, to ensure patients receive the right care, at the right time, by the right provider.
3. “Develop a better understanding, in partnership with third-party payers, on how to best maximize health outcomes using currently available funding.” This involves discussing with all stakeholders, the best allocation of limited resources to help patients effectively, and safely manage their MSK conditions. There is only so much money in the pot, so we need to make the best use of it.
4. “Invest in research to fully understand the breadth of the opioids crisis and burden of MSK conditions and allow for the creation of comprehensive approaches to managing chronic, non-cancer pain.” The opioid crisis is huge, and multifactorial. We need more research to be able to truly understand what effect MSK conditions are having on the issue, so we can better manage it.
Well, this post was longer than I had anticipated, but the problem deserves to be talked about so we can start to implement solutions. Obviously this isn’t a problem some chiropractors are going to solve – it’s much bigger than that, but I hope you can see how appropriate management of MSK pain can be a part of the fix.
Thanks for reading,
Dr. Lee Brotherston
Oak Ridges Health Group
A Better Approach to Pain Management. (2016) Toronto. Retrieved from https://www.chiropractic.ca/wp-content/uploads/2016/11/A-Better-Approach-to-Pain-Management-in-Canada3-1.pdf
Assessing the Harms of Opioids. (2017). Ccsa.ca. Retrieved 14 January 2017, from http://www.ccsa.ca/Eng/collaboration/Partnerships-to-Address-Prescription-Drug-Misuse/Assessing-harms-of-opioids/Pages/default.aspx
Kolodny, A., Courtwright, D., Hwang, C., Kreiner, P., Eadie, J., Clark, T., & Alexander, G. (2015). The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annual Review Of Public Health, 36(1), 559-574. http://dx.doi.org/10.1146/annurev-publhealth-031914-122957
NIDA (2016). Misuse of Prescription Drugs. Retrieved January 14, 2017, from https://www.drugabuse.gov/publications/research-reports/misuse-prescription-drugs
Prescription Drug Abuse. (2017). Nsc.org. Retrieved 14 January 2017, from http://www.nsc.org/learn/nsc-initiatives