The objective of this analysis was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain. The researchers employed a retrospective cohort design for analysis of health claims data from three contiguous US states for the years 2012-2017.
They included adults aged 18-84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain. Two cohorts of subjects were thus identified:
- patients who received both primary care and chiropractic care,
- Patients who received primary care but not chiropractic care.
The total number of subjects was 101,221. Overall, between 1.55 and 2.03 times more nonrecipients of chiropractic care filled an opioid prescription, as compared with recipients.
The authors concluded that patients with spinal pain who saw a chiropractor had half the risk of filling an opioid prescription. Among those who saw a chiropractor within 30 days of diagnosis, the reduction in risk was greater as compared with those with their first visit after the acute phase.
Similar findings have been reported before and we have discussed them on this blog (see here, here and here). As before, one has to ask: WHAT DO THEY ACTUALLY MEAN?
The short answer is NOTHING MUCH! And certainly not what many chiros make of them.
They do not suggest that chiropractic care is a substitute for opioids in the management of spinal pain.
Why?
There are several reasons. Perhaps the most important ones are that such analyses lack any clinical outcome data, and that comparing one mistake (opioid-overuse) whith what might be another (chiropractic care) is a wrong apporoach. Imagine a scenario where half to the patients had received, in addition to their usual care, the services of:
- a paranormal healer,
- a crystal therapist,
- a shaman,
- or a homeopath.
Nobody would be surprised to see a very similar result, particularly if all of these practitioners were in the habit of discouraging their patients from using conventional drugs. Or imagine a scenario where half of all patients suffering from spinal pain are entered into an environment where they receive no treatment at all. Who would not expect that this regimen does not dramatically reduce the risk of filling an opioid prescription? But would that indicate that zero treatment is a good solution for managing spinal pain?
The thing is this:
- If you want to reduce opioid use, you need to prescribe less opioids (for instance, by re-educating doctors to do as they have been told in med school and curb over-prescribing).
- If you discourage patients to use opioids (as many other healthcare professionals would), many will not use opioids.
- If you want to know whether chiropractic is effective in managing spinal pain, you need to conduct a well-designed clinical trial.
Or, to put it simply:
CORRELATION IS NOT CAUSATION!
15 Responses to Chiropractic patients have only half the risk getting an opioid prescription – but what does it mean?
Leave a Reply to Kim Forehand van der Linde Cancel reply
This site uses Akismet to reduce spam. Learn how your comment data is processed.
Thanks, one to add to the growing list…
Among New Hampshire adults with office visits for noncancer 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 nonrecipients. https://www.liebertpub.com/doi/full/10.1089/acm.2017.0131
A higher per-capita supply of DCs and Medicare spending on CMT were inversely associated with younger, disabled Medicare beneficiaries obtaining an opioid prescription. https://www.sciencedirect.com/science/article/pii/S0161475416000634
These results suggest that education about realistic expectations for chronic pain management and therapy options, as well as making A/C care more easily accessible, might lead to more satisfaction for patients and providers, and provide important input to policy makers. https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-016-0566-0
Our meta-analysis of 3 studies (n=51 069 workers) confirmed a strong association between early opioid use and prolonged claim duration. https://bmjopen.bmj.com/content/5/8/e007836.short
The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before. https://academic.oup.com/painmedicine/article/19/suppl_1/S54/5089431
In 2009, two VHA directives were issued addressing the availability of chiropractic care19 and implementation of stepped care,20 emphasizing a biopsychosocial understanding of chronic pain. Increased provision of alternatives to opioid therapy may have contributed to decreased opioid use. https://link.springer.com/article/10.1007/s11606-017-4283-8
CORRELATION IS NOT CAUSATION!
Please remember that next time we discuss cx manipulation and cervical artery dissections.
thank you for this little patronising lesson in science.
I never claim that cases of AEs prove anything; they merely alert us to a possibility that requires further work and caution.
IT IS THE CHIROPRACTIC PROFESSION WHO LISTEN TO THIS SINCE 2 DECADES AND EVEN FAIL TO ESTABLISH A AE MONITORING SYSTEM!
An AE reporting system might helps us identify at risk populations, those which we are currently unaware of.
Of course for it to have any value chiros and neurologists would need to work closely together on reporting these cases.
Fear mongering and the spreading of false and misleading information deters such a collaboration.
Who is part of the problem and who is part of the solution?
I doubt that many Complementary Alternative Healthcare practitioners have any inclination to listen to someone who thinks that the clever acronym SCAM is the way of addressing them…… It only alienates people and inhibits conversations that are needed…..
@EE
Edzard no one has an AE reporting system, chiro, physio, GP’s in private practice etc.. We tried to set one up here in ER’s years ago (supported by chiro’s) in Melbourneand it was killed off by DOCTORS.
If there is an AE by a non-chiro who manipulates the cervical spine and it is pointed out to you, say like here by a physio here;
https://www.abc.net.au/news/2019-08-05/concerns-over-the-rise-of-resistant-superbugs/11377930
“Mr Fox had developed a clot on his brain following a neck manipulation by a physiotherapist, officially known as a carotid artery dissection.”
I pointed it out to both of you several times and you both ignored it.
Imagine the screams from you, Blue Wode and Co on social medial if this ABC article had been about a chiro.
You would be posting it across all mediums, adding it to the Chiropractic Wikpedia page, writing a blog, posting your blog on Twitter over and over and over, asking where is the physio’s AE reporting system, claiming the physio’s are burying their heads in the sand, physio’s ignoring the precautionary principle, physio’s are wasting $150,000 “education”, idiotic pre-science dogma, sententious, pretensions of efficacy and expertise and overpriced placebos and entrepreneurial theatrics masquerading as healthcare to convince a small percent of people that there are alternatives to opioids, yada, yada…… Oops I mean Chiro.
Sorry typo after reading that ABC article.
Wonder how the medical reporter would have written the article if it had been a chiro?
Critical_Chiro wrote: “Edzard no one has an AE reporting system, chiro, physio, GP’s in private practice etc.. We tried to set one up here in ER’s years ago (supported by chiro’s) in Melbourne and it was killed off by DOCTORS.”
@ Critical_Chiro
Prof. Ernst has already addressed your argument here:
https://edzardernst.com/2018/12/another-serious-complication-after-chiropractic-manipulation-best-to-avoid-neck-manipulations-altogether-i-think/#comment-107915
Critical_Chiro wrote: “Mr Fox had developed a clot on his brain following a neck manipulation by a physiotherapist, officially known as a carotid artery dissection.” I pointed it out to both of you several times and you both ignored it.”
[Fox ref: https://www.abc.net.au/news/2019-08-05/concerns-over-the-rise-of-resistant-superbugs/11377930 ]
I didn’t ignore it. See https://twitter.com/Blue_Wode/status/1166260426428047360
“…it was killed off by DOCTORS.”
without any evidence, this is just his opinion.
So a nonsensical $150,000 “education”, idiotic pre-science dogma, sententious, pretensions of efficacy and expertise and overpriced placebos and entrepreneurial theatrics masquerading as healthcare to convince a small percent of people that there are alternatives to opioids? As you suggest where are the astrologers and psychics when you need them?
yah, those silly PTs, doing what many chiros do, suggesting such nonsense…
http://www.apta.org/uploadedFiles/APTAorg/Advocacy/Federal/Legislative_Issues/Opioid/SafeAlternativeToOpioids.pdf
https://www.ptnow.org/opioid
Comparing the range of musculoskeletal therapies applied by physical therapists with postgraduate qualifications in manual therapy in patients with non-specific neck pain with international guidelines and recommendations: An observational study.
https://www.sciencedirect.com/science/article/abs/pii/S2468781219304667
“High velocity-thrust manipulation is applied frequently (33.8%).”
Yah @MK, those silly PT’s jumping on the high velocity thrust to the cervical spine band wagon with minimal training, suggesting such nonsense with 4 times as many physio’s as chiro’s………
My goodness next thing you know their adverse events will be ignored and under reported:
https://www.abc.net.au/news/2019-08-05/concerns-over-the-rise-of-resistant-superbugs/11377930
much of physical therapy isn’t based upon high quality evidence.
and some of it on no evidence at all.
Sometimes we just have to do what we can with what we know…trial of care.