Six Things Every Chiropractor Should Know About Opioids
Public Health, Wellness & Prevention Contributors
Contributed by Claire Johnson, DC, MsEd, PhD, Bart Green, DC, MsEd, PhD, and Michael Haneline, DC, MPH
An increase in addictions and deaths due to opioids has raised significant concern and media attention. We offer this brief overview on this important public health problem for the practicing chiropractor.
1. What Are Opioids?
Opioid medications are prescribed to reduce pain; however, they are addictive and can be dangerous. Although some suggest there is "no safe dose" for opioids, these drugs may be helpful for people with severe pain, such as those experiencing pain from cancer. However, over the past several decades, more patients have been prescribed opioids for musculoskeletal pain, such as back or neck pain, instead of being provided with nondrug therapies.
As with any drug, opioids have side effects and may "adversely affect respiratory, gastrointestinal, musculoskeletal, cardiovascular, immune, endocrine, and central nervous systems."1 As the dose increases, the risks for overdose and health concerns also increase, including "fractures, addiction, intestinal blockages, and sedation."1 If too high a dose is consumed or if opioids are taken with certain other drugs or alcohol, death may result.
2. Why Is Opioid Use / Overuse Problematic?
Since 1999, prescription opioid sales have increased fourfold, along with a surge in the use of opioids as a first line for pain management, rather than only for severe cancer-related pain. This trend has led to burgeoning opioid prescribing in the U.S.:2
One in five people with non-cancer pain have been prescribed opioids.
More than 165,000 prescription opioid-related deaths occurred between 1999 and 2014.
An estimated 2 million people were addicted to opioids as of 2014.
3. Who Is Addressing This Health Crisis?
Currently, many professions are seeking ways to address this national epidemic. The medical profession has launched various initiatives to help medical doctors (MDs) reduce prescriptions. These include an initiative to remove pain as the 5th vital sign, and promoting guidelines for when to prescribe and how to better manage patients in pain without the use of opioids.
The Centers for Disease Control and Prevention (CDC) has released guidelines to curb opioid prescriptions, with the following categories of recommendations to those who prescribe opioids: 1) determine when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, discontinuation, and assessing risk; and 3) addressing harms of opioid use.
In addition to these efforts, even more focus is needed to assist people who seek help for pain and to provide them with nonpharmacological alternatives.
4. What Can Doctors of Chiropractic Do?
Chiropractic care can be part of the solution. DCs can work with other health care providers and support policy to offer alternatives to opioids for addressing patients in pain, especially chronic non-cancer pain.
Although there are no large trials comparing outcomes of chiropractic care to opioids, we do know opioid use is associated with worse functioning in back pain patients at six-month follow-up3 and greater disability;4 and that injured workers whose first health care visit is to a DC have better outcomes.5 We also know that the per-capita supply of DCs and higher use of manipulative therapy is associated with lower rates of opioid prescriptions among Medicare recipients.6
All this suggests chiropractic care may help reduce the use of and need for opioid prescriptions for back pain sufferers; and may play an important role in reducing the opioid epidemic by helping to prevent patients from ever getting an opioid prescription in the first place.
Important resources DCs should be aware of include:
5. What Can We Do If a Patient Is Already Taking Opioids?
Most chiropractors take a history and ask patients what medications they are taking. The first step is to recognize that the following are opioid-class drugs: hydrocodone (Vicodin), ultram (Tramadol), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza) and codeine.7
Once we know a patient is taking opioids, we must first seek to understand the situation before we provide education. Questions we can ask include:
For what condition is the patient taking the medication?
How long has the patient been taking opioids and at what daily dose?
Who is the provider watching over their prescription? Is more than one provider prescribing opioids?
When was the last time the patient saw the prescribing physician and when is the next appointment?
Does the patient have any safety issues? For example, does the patient operate machinery? Is the patient experiencing side effects such as "sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, or respiratory depression"?8
What is the patient's level of function? Are there any psychological flags or addictive behaviors?
Is the patient taking any other substances or drugs that may have deadly interactions, such as alcohol, benzodiazepines and/or other opioids?
As chiropractors, we can discuss treatment goals, such as reasonable functional activity; and pain goals with and without medication. We also can discuss potential adverse events, including the risks for side effects, addiction and death. We can inform patients of other dangers they may not be aware of, such as the deadly combination of opioids when combined with other drugs that depress CNS activity (e.g., alcohol or drugs for anxiety such as benzodiazepines).
We can encourage patients to contact the prescribing provider to discuss reducing and stopping opioid use, and to ask for safer alternatives for pain control, such as chiropractic care, physical therapy, acupuncture and mind-body methods. If a patient is already addicted, we can encourage the patient to seek a specialist provider and addiction care program. (Note that some patients may need to remain on opioids, such as for cancer pain or end-of-life care.)
Most importantly, we can work with the patient and their prescribing provider to offer them nonpharmacological care to help reduce their pain and help them reach their functional goals.
6. How Can We Collaborate More on Solutions?
As DCs, we can work more closely with local MDs and discuss better ways to collaborate concerning patients with pain. Remember that MDs are not the enemy, but are an essential component of the solution to this epidemic. Most MDs are also extremely concerned about the opioid epidemic, and are looking for efficient and cost-effective ways of helping their patients. We should remain professional when speaking about MDs with our patients, as our patients likely have good relations with them.
We can be part of the safety net to help reduce the number of people who become addicted or die from overdose. As we work with other health care professionals and our patients, we can remind them that the first recommendation per the CDC's Guideline for Prescribing Opioids for Chronic Pain is "Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain."9 Thus, through collaboration, the chiropractic profession can be a part of the solution.
References
Baldini A1, Von Korff M, Lin EH. A review of potential adverse effects of long-term opioid therapy: a practitioner's guide. Prim Care Companion CNS Disord, 2012;14(3).
Ashworth J, Green DJ, Dunn KM, Jordan KP. Opioid use among low back pain patients in primary care: is opioid prescription associated with disability at 6-month follow-up? Pain, 2013 Jul;154(7):1038-44.
Franklin, GM, Stover, BD, Turner, JA, et al. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine, 2008;33:199-204
Turner JA, Franklin G, Fulton-Kehoe D, et al. ISSLS prize winner: early predictors of chronic work disability: a prospective, population-based study of workers with back injuries. Spine, 2008 Dec 1;33(25):2809-18.
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 May;39(4):263-6.
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