This week from Dr. Cerami and Utah Sports and Wellness
Although there is little evidence that opioids improve chronic pain, function or quality of life, more than 650,000 opioid prescriptions are dispensed per day in the United States. Among these US adults, 59% are prescribed opioids for reporting back pain. Clinical guidelines from The American College of Physicians recommend non-pharmacologic treatment as the first-line approach to treating back pain, with consideration of opioids only as the last treatment option. A recent systematic review and meta-analysis found that for treatment of acute low back pain, spinal manipulation provides a clinical benefit equivalent to that of NSAIDS, with no evidence of serious harms. Among patients with low back pain, recipients of services delivered by Doctors of Chiropractic have a lower likelihood of using prescription opioids, compared with non-recipients.
Mortality rates due to adverse drug events (ADEs) are escalating in the United States. Analgesics are among the drug classes most often associated with occurrence of an ADE. Utilization of non-pharmacologic chiropractic services for treatment of low back pain could lead to reduced risk of an ADE. The objective of this investigation was to evaluate the association between utilization of chiropractic services and likelihood of an ADE. We employed a retrospective cohort design to analyze health insurance claims data from the state of New Hampshire. After inversely weighting each participant by their propensity to be in their cohort, we employed logistic regression to compare recipients of chiropractic services to non-recipients with regard to likelihood of occurrence of an ADE in an outpatient setting. The risk of an ADE was significantly lower among recipients of chiropractic services as compared with non-recipients. The adjusted likelihood of an ADE occurring in an outpatient setting within 12 months was 51% lower among recipients of chiropractic services as compared to non-recipients (OR 0.49; P = .0002). The reported ADEs were nonspecific with regard to drug category in the majority of incidents that occurred in both cohorts. Among New Hampshire adults with office visits for low back pain, the adjusted likelihood of an ADE was significantly lower for recipients of chiropractic services as compared to non-recipients. No causal relationship was established between utilization of chiropractic care and risk of an ADE. Future research should employ larger databases, rigorous methods to reduce risk of bias, and more sensitive means of identifying ADEs.
These authors also note:
- “More aggressive pain management efforts that began in the 1990s have led to an epidemic of prescriptions for opioid pain medications in the U.S.”
- “Long-term use of opioids is associated with overdose, misuse, abuse, and opioid use disorder.”
- “After as few as 5 days of taking opioids, the chance of an opioid-naive patient being a chronic opioid user sharply increases.”
• 1 day of opioid exposure carries a 6% chance of being on opioids 1 year later.
• 8 days of opioid exposure carries a 13.5% chance of being on opioids 1 year later.
• 31 days of opioid exposure carries a 30% chance of being on opioids 1 year later.
- “Little attention has been paid to the potential of non-pharmacologic pain treatment as an upstream strategy for addressing the opioid epidemic.”
- “A recent systematic review and meta-analysis found that for treatment of acute low-back pain, spinal manipulation provides a clinical benefit equivalent to that of NSAIDs, with no evidence of serious harms.”
- Spinal manipulation is an effective treatment for chronic low-back pain.
- “Among New Hampshire adults with office visits for non-cancer low-back pain, the adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower for recipients of services provided by Doctors of Chiropractic compared with non-recipients.”
- “Average charges per person for chiropractic users—for both opioids and office visits for low-back pain—were also significantly lower compared with nonusers over a 2-year period.”
- Chiropractic care “could exert a positive impact on patients with low-back pain by reducing unnecessary care, lowering costs, and improving safety.”
- “Pain relief resulting from services delivered by Doctors of Chiropractic may allow patients to use lower or less frequent doses of opioids, leading to reduced risk of adverse effects.”
- The filling of a prescription for an opioid analgesic was 55% lower among chiropractic recipients compared with non-recipients.
- “Conclusions: Among New Hampshire adults with office visits for non-cancer low-back pain, the likelihood of filling a prescription for an opioid analgesic was significantly lower for recipients of services delivered by Doctors of Chiropractic compared with non-recipients.”
- These authors considered the benefits of receiving chiropractic services for both reduced costs and reduction of opioid use to be “impressive.”