Opioids now account for nearly two-thirds of all overdose-related deaths in the U.S. This insidious bane is no respecter of gender, age, race or ethnicity, with nearly all categories experiencing increases. Since 2015, overdose deaths from heroin are up 19.5 percent, prescription opioids 10.6 percent; and in a disturbing rise, death rates from synthetic opioids (such as fentanyl) have risen by more than 100 percent.1
Over 80 percent of heroin addicts report first abusing prescription narcotics for pain relief, underlying the moral imperative for the chiropractic profession to educate the general population and medical profession on the role chiropractic care should play in the fight against opioid addiction. (I won't rehash the evidence of chiropractic efficacy in treating these conditions, as it is readily available.)
The Neuroscience of Opioid Addiction
Our current understanding is that the rewarding and addictive properties of opiate drugs are mediated by dopamine (DA) neurotransmission in the mesolimbic system. These DA neurons originate in the ventral tegmental area (VTA) of the midbrain and project to the nucleus accumbens (NAc) in the ventral striatum.
Increased levels of DA are associated with increased reward.2 These levels increase with acute consumption of drugs of abuse, providing a reinforcing stimulus for further use.3-4 During withdrawal, DA neurons become hypoactive while GABA neurons become hyperactive.5-8 Both contribute to a reduction in dopamine neurotransmitter release that is theorized to be the primary driver of withdrawal and relapse.9
Opioid Receptors
There are three classic opioid receptor types: kappa (KOR), mu (MOR), and delta (DOR).10-14 Their respective roles in drug abuse disorders are varied, complex and not fully understood. We do know that drugs acting on any of these receptors will produce pain relief through their actions in the spinal cord, brain stem and thalamus.
However, MORs and DORs (the target of prescription opiates and drugs like heroin) produce euphoria through their additional effects on the prefrontal cortex, VTA and NAc.15 Thus, they carry a high risk for dependence and abuse. Conversely, drugs that activate KORs, like the psychotropic salvinorin, produce dysphoria and are not well-suited for use in pain management.16-17
A Physiological Disease or a Psychological Disorder?
Whether addiction is a physiological disease has become hotly contested over the past year. Proponents of addiction as a disease point to the clear changes that occur in the neural circuitry of myriad brain regions as evidence of a progressive disease state. The definition published by the National Institute on Drug Abuse (NIDA) characterizes addiction as a "chronic, relapsing brain disease."
Others argue that although undoubtedly, brain changes occur in an addicted state, these changes are consistent with changes that occur in any behavioral or habitual activity that is exceedingly rewarding. Perhaps its classification is less important than the approach we take to prevent or treat.
I believe the truth in this debate likely lies within both camps. In fact, evidence is clear that a comprehensive approach including, DCs, MDs and PsyDs is far more effective than any one provider trying to treat on their own.
Be wary of approaches that provide the same treatment plan to everyone. The best treatment approaches are individualized and shaped based upon age, race, culture, gender, family, housing, employment, and physical, mental and sexual abuse.
The Spine and Addiction: A Role for Chiropractic?
DCs are uniquely positioned to lead in the battle against opioid addiction for several reasons. First and most obvious, chiropractic care can reduce chronic, intractable pain without the use of narcotic pain medications. Even in situations in which chiropractic care leaves a patient at maximum medical improvement with residual pain, there is a strong argument to be made for utilizing long-term maintenance care as opposed to long-term narcotic painkillers.
This argument has only been strengthened with recent death rates. We needn't shy away from chronic pain maintenance care; it can literally save lives.
Second, there is emerging data suggesting the spine may play a more pivotal role in the circuitry of addiction than previously thought. Data published by Brigham Young University and Daegu Haany University in South Korea show a neurological connection from peripheral mechanoreceptors to the mesolimbic system described above. These studies utilized a variant type of mechano-acupuncture to activate peripheral mechanoreceptors – the same types activated when a patient receives a chiropractic adjustment.
So far, this type of mechanoreceptor-based therapy has been shown to not only involve the opiate pathways in the brain, but also to mitigate drug-seeking behavior in the context of ethanol,18 cocaine19 and methamphetamines.20 In short, when a patient is in withdrawal, stimulation of peripheral mechanoreceptors can calm the part of their brain that's out of control. This calming takes place by inhibition of GABA neurons in the ventral tegmental area and is thought to contribute to the noted decrease in drug-seeking behavior.
Further, the pathways underlying these effects are being elucidated and are integrally related to the science of chiropractic. They act, in large part, through activation of the dorsal column medial lemniscal pathway (DCML).21 This pathway should cause every chiropractor's spine to tingle. It is central to every adjustment given to every patient since D.D. met Harvey.
Regardless of technique, mechanoreceptors function as intermediaries between the doctor and the patient's brain, and the DCML is the neurological pathway that provides us access. Research into this connection is ongoing, with several more papers to be published in the next six months that will shed further light on the power the adjustment has to influence brain function.
The Bottom Line
Chiropractors have an increasingly justified case to be more involved in solving the opioid crisis. Though pharmacological treatments for addiction should not be overlooked, logic dictates that only using an addictive chemical to treat the effects of an addiction to a chemical would not likely produce the highest rates of success.
We have a moral duty to provide the best care possible to our patients, and the data is suggestive that an all-of-the-above approach provides the highest probability of a good outcome. All of the above includes us!
References
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
