The Role of Chiropractic Care in Reducing Opioid Use

July 2020

Research summary includes articles from 2016-May 2020

  • A 2020 systematic review and meta-analysis investigated the association between chiropractic use and opioid receipt. Databases were searched through April 18, 2018 and controlled studies, cohort studies, and case-control studies including adults with noncancer pain. A total of 6 articles were included in the analysis; 5 focused on back pain and 1 on neck pain. Between 11-51% of spinal pain patients used chiropractic. Fewer chiropractic users received an opioid prescription (range = 12-57%) than nonusers (range = 31-66%). Chiropractic users had 64% lower odds of receiving an opioid prescription than nonusers (odds ratio = 0.36).1
  • A 2020 retrospective cohort study evaluated the impact of chiropractic utilization on use of prescription opioids among patients with spinal pain. Those who received both primary medical care and chiropractic care were compared to those who received primary medical care but not chiropractic care. Of 101,221 patients in the dataset, 1.55-2.03 times more nonrecipients of chiropractic care filled an opioid prescription, compared to recipients of chiropractic care. The authors concluded that patients with spinal pain who saw a chiropractor had half the risk of filling an opioid prescription.2
  • A 2019 retrospective cohort study of a national sample of 216,504 opioid-naive adults with new-onset LBP compared those who initially saw a primary care medical physician to those who initially saw a physical therapist, chiropractor or acupuncturist. It found that initial visits to any of these conservative practitioners is associated with substantially decreased early and long-term use of opioids.3
  • A 2018 cohort study found that among New Hampshire adults with office visits for noncancer low-back pain, the likelihood of filling an opioid prescription was significantly lower for recipients of chiropractic services compared with nonrecipients.4
  • 2018 cohort study found that among New Hampshire adults with office visits for low back pain, the adjusted likelihood of an adverse drug event was significantly lower for recipients of chiropractic services compared to nonrecipients.5
  • A 2018 retrospective cohort study examined use of opioids and 21 specific nonpharmacologic therapies (NPT) used by 49,885 veterans with low back pain. It found that 34% filled an opioid prescription, 35% utilized at least 1 NPT modality, and 15% used both within the same year. About 43% of NPT users also were prescribed an opioid.6
  • A 2018 retrospective cohort study using VHA administrative data described veterans using specialty pain services. Only 1.9% used complementary and integrative health (CIH) services. After accounting for key covariates and potential confounders, veterans who used a CIH-related service were less likely to receive an opioid analgesic prescription in the 365 days following the index visit.7
  • A 2016 retrospective cohort investigated the association between use of chiropractic among younger and more disabled Medicare recipients and opioid use. It found that a higher per-capita supply of DCs and higher Medicare spending on chiropractic services were inversely associated with younger, disabled Medicare beneficiaries obtaining an opioid prescription.8 

Nonpharmacological approaches to chronic musculoskeletal pain management

  • A 2018 prospective cohort study examined the treatment goals of chiropractic patients with chronic spinal pain. It found that over 2/3 of patients’ goal was pain management, as opposed to pain cure. This is in direct conflict with the implicit goal of most experimental studies of spinal manipulation, which are based on a curative model, in which spinal manipulation is found ineffective if it does not permanently “cure” chronic pain. This study points to the inconsistency between patients’ practical use of spinal manipulation to manage their pain and the attitude in the healthcare mainstream, in which pharmacological approaches such as opioids are used for pain management but nonpharmacological approaches such as spinal manipulation are considered ineffective if they are required on an ongoing basis to manage pain. The results of this study have important policy implications.9
  • A comprehensive 2018 systematic10 review and its 2020 update,11 both by the Agency for Healthcare Research and Quality (AHRQ) assessed which noninvasive nonpharmacological treatments for five common chronic pain conditions improve function and pain for at least 1 month after treatment. Although most effects were small, there was no evidence suggesting serious harms. Their findings were:
  • Chronic low back pain: Exercise, psychological therapies (primarily cognitive behavioral therapy (CBT), spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, multidisciplinary rehabilitation (MDR).
  • Chronic neck pain: Exercise, low-level laser, Alexander Technique, acupuncture.
  • Knee osteoarthritis: Exercise, ultrasound.
  • Hip osteoarthritis: Exercise, manual therapies.
  • Fibromyalgia: Exercise, CBT, myofascial release massage, tai chi, qigong, acupuncture, MDR.
  • Chronic tension headache: Spinal manipulation.10
  • A 2018 White Paper details the historical context and magnitude of the current pain problem and the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies, Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.12

 

References

  1. Corcoran KL, Bastian LA, Gunderson CG, Steffens C, Brackett A, Lisi AJ. Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis. Pain Med. 2020;21(2):e139-e145. https://www.ncbi.nlm.nih.gov/pubmed/31560777
  2. Whedon JM, Toler AWJ, Kazal LA, Bezdjian S, Goehl JM, Greenstein J. Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain. Pain Med. 2020. https://www.ncbi.nlm.nih.gov/pubmed/3214214
  3. Kazis LE, Ameli O, Rothendler J, 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;9(9):e028633. FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pubmed/31542740
  4. Whedon JM, Toler AWJ, Goehl JM, Kazal LA. Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain and Use of Prescription Opioids. J Altern Complement Med. 2018;24(6):552-556. https://www.ncbi.nlm.nih.gov/pubmed/29470104
  5. Whedon JM, Toler AWJ, Goehl JM, Kazal LA. Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Risk of Adverse Drug Events. J Manipulative Physiol Ther. 2018;41(5):383-388. https://www.ncbi.nlm.nih.gov/pubmed/29843912
  6. Vanneman ME, Larson MJ, Chen C, et al. Treatment of Low Back Pain With Opioids and Nonpharmacologic Treatment Modalities for Army Veterans. Med Care. 2018;56(10):855-861. FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pubmed/30134347
  7. Ashrafioun L, Allen KD, Pigeon WR. Utilization of complementary and integrative health services and opioid therapy by patients receiving Veterans Health Administration pain care. Complement Ther Med. 2018;39:8-13. https://www.ncbi.nlm.nih.gov/pubmed/30012396
  8. Weeks WB, Goertz CM. Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic and Opioid Use in Younger Medicare Beneficiaries. J Manipulative Physiol Ther. 2016;39(4):263-266. FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pubmed/27034107
  9. Herman P, Edgington S, Ryan G, Coulter I. Prevalence and characteristics of chronic spinal pain patients with different hopes (treatment goals) for ongoing chiropractic care. J Altern Complement Med. 2019. FREE FULL TEXT: https://www.liebertpub.com/doi/10.1089/acm.2019.0247
  10. Skelly AC CR, Dettori JR, et al,. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. In. Rockland, MD: AHRQ; 2018. FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/books/NBK519953/
  11. Skelly AC, Chou R, Dettori JR, et al. In: Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update. Rockville (MD)2020. FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pubmed/32338846
  12. Tick H, Nielsen A, Pelletier KR, et al. Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper. Explore (NY). 2018;14(3):177-211. FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pubmed/29735382

A literature synthesis of the role of Chiropractic Care in reducing Opioid Use — an academically rigorous analysis of all the available scientific literature using internationally accepted tools to rate each article according to specific criteria indicating only what we can conclude with supportable, scientific evidence.