Addictionology, Back Pain and Chiropractic

According to the National Institutes of Health, "Unhealthy substance use, and addiction is the nation's largest preventable health problem, yet only about 10% of patients receive treatment for it. This new subspecialty is important in helping eliminate the personal and public health consequences and the stigma associated with addiction by reinforcing that it is a preventable, treatable disease and by providing patients with access to credentialed physicians. Addiction Medicine (ADM) is now a recognized physician subspecialty of the American Board of Medical Specialties."¹

Back pain is the leading cause of disability worldwide, with approximately 37 percent of the population affected by low back pain.² Acute low back pain (LBP), if unresolved, is considered chronic if it persists for more than three months; and is experienced by 70-80 percent of adults in their lifetime.³

As many as nine in 10 patients (85-90 percent) with chronic low back pain (CLBP) have pain that cannot be determined from a definitive pathoanatomic structure and therefore is termed non-specific.⁴  Non-specific LBP in an overall setting (acute and chronic) is defined as LBP with no attributable known cause and represents 90-95 percent of cases.⁵

The Problem: Opioid Prescriptions

Of those 85-90 percent of CLBP patients and upwards of 95 percent for all cases, they arise from acute low back pain with no definitive pathoanatomic cause (mechanical spine pain with no fracture, tumor, infection, or herniation). Of these acute patients, medical primary care providers prescribe LBP patients opiates in 24.4 percent of cases, urgent care facilities in 40.8 percent, and emergency-room physicians in 43.1 percent.⁶

Etiology Points to the Solution

Of the 95 percent non-specific back pain, the literature has provided extensive evidence of the etiology when describing the genesis of spinal pain. Spinal meniscoids impingements, which are intra-articular folds of the synovial membrane, provide evidence of a pathoanatomical source of pain.⁷ In acute and chronic settings, there is a direct activation of nociceptor afferents whereby the sensitization and desensitization of pro- and anti-inflammatory mediators may modulate spinal pain. There is also central sensitization with widespread issues of mechanical pain sensitivity originating in the disc, facet, joint capsules, and ligaments.⁸

A chiropractic spinal adjustment (manipulation) inhibits neck and back pain through segmental and peripheral mechanisms regulating the inflammatory response.⁹ The meniscoid entrapment, which created pain, also creates a "tractioning" effect on the zygapophyseal joint capsule (mechanoreceptors), further leading to central sensitization.

A chiropractic high-velocity, low-amplitude thrust/adjustment (HVLAT) stretches the joint, providing "joint gapping" and the "treatment of choice" for meniscoid entrapment, and reduces the pain created by the biomechanical pathology.¹⁰

The Massive Impact on Health Care

In 2018, it was reported that average annual charges per person for filling opioid prescriptions were 74 percent lower among chiropractic patients compared with other forms of treatment. For clinical services provided at office visits for low back pain, average annual charges per person were 78 percent lower among chiropractic patients compared with other forms of treatment. The likelihood of a prescription for an opiate analgesic was 55 percent lower among chiropractic patients compared with other forms of treatment.¹¹

In 2020, the prevalence of chiropractic care among patients with spinal pain varied between 11.3 percent and 51.3 percent. The proportion of patients receiving an opioid prescription was lower for chiropractic users compared with other forms of treatment. Chiropractic patients had 64 percent lower odds of receiving an opioid prescription compared with other forms of treatment.

In 2016, it was reported that medical care prolonged spinal-related compensation 12 percent longer than chiropractic, and physical therapy care required 239 percent more time to end full compensation than chiropractic. Medical care also required 20 percent more time, and physical therapy 313 percent more time, versus chiropractic care regarding partial compensation.¹²

Addiction Specialists Understand

Despite the evidence in the literature, prominent medical establishments such as the Mayo Clinic still list chiropractic as an alternative footnote after listing physical therapy, drugs (including antidepressants and narcotics), surgery, implanted nerve stimulators, a radiofrequency neurotomy (surgery), steroid injections, all of which do nothing as primary treatment modalities. Herein lies part of the societal problem of dependence and the necessity for creating an addiction specialist.¹³

However, with the advent of an addiction specialist, they have understood and searched for a solution to the underlying cause of the fifth most prevalent reason for visiting a U.S. doctor, low back pain.¹⁴ Addiction specialists are searching for the eradication of the cause of the pain that has led to opiate use initially, and chiropractic outcomes have warranted inclusion into their treatment plans for the management of substance addiction.

The challenge addiction specialists must overcome with using chiropractic is coverage issues, particularly Medicaid and workers' compensation systems that place unrealistic roadblocks. These systems, in every state, offer full coverage for services that realize 64 percent higher opiate use and a 313 percent increase in disability, yet still prevent patients from receiving "evidence-based care" that prevents opiate addiction.

Despite these poor outcomes, money continues to be drained from our health care system, lives are severely disrupted, and people are dying unnecessarily.

References

1. "About the Addiction Medicine Subspecialty." National Institutes of Health, National Institute on Drug Abuse, 2018.
2. Gevers-Montoro C, et al. Chiropractic spinal manipulation prevents secondary hyperalgesia induced by topical capsaicin in healthy individuals. Front Pain Res, 2021:33.
3. Paolucci T, et al. Chronic low back pain and postural rehabilitation exercise: a literature review. J Pain Res, 2019;12:95.
4. Tagliaferri SD, et al. Domains of chronic low back pain and assessing treatment effectiveness: a clinical perspective. Pain Pract, 2020;20(2):211-225.
5. Oliveira CB, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Euro Spine J, 2018;27(11):2791-2803.
6. Azad TD, et al. Initial provider specialty is associated with long-term opiate use in patients with newly diagnosed low back and lower extremity pain. Spine, 2019;44(3):211-218.
7. Farrell SF, et al. Cervical spine meniscoids: an update on their morphological characteristics and potential clinical significance. Euro Spine J, 2017;26:939-947.
8. Gevers-Montoro C, et al. Neurophysiological mechanisms of chiropractic spinal manipulation for spine pain. Euro J Pain, 2021;25(7):1429-1448.
9. Ibid.
10. Evans DW. Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories. JMPT, 2002;25(4):251-262.
11. Whedon JM, et al. Association between utilization of chiropractic services for treatment of low-back pain and use of prescription opioids. J Compl Alt Med, 2018;24(6):552-556.
12. Corcoran KL, et al. 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.
13. Back Pain. Mayo Clinic, 2021: www.mayoclinic.org/diseases-conditions/back-pain/diagnosis-treatment/drc-20369911.
14. Urits I, et al. Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment. Curr Pain Headache Rep, 2019;23(3):1-10.