Research Review By Dr. Jeff Muir©

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Date Posted:

February 2020

Review Title:

Can Seeing a Chiropractor Reduce Opioid Use in Low Back Pain Patients?

Papers Reviewed:

  1. Kazis LE, Ameli O, Rothendler J et al. Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open 2019; 9: e028633.
  2. Corcoran KL, Bastian LA, Gunderson CG et al. Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis. Pain Medicine 2019; Sep 27. pii: pnz219. doi: 10.1093/pm/pnz219. [Epub ahead of print].

Background Information:

Opioid use has increased substantially over the past decade, with current estimates suggesting that over 12 million Americans report long-term use (or misuse) of opioid medication (1-3). Musculoskeletal complaints, specifically low back pain (LBP), are a common condition precipitating opioid prescription (2-4), with more than half of opioid users reporting a history of LBP (5). The introduction of guidelines for opioid use and prescription by the Centers for Disease Control (CDC) and the American College of Physicians (6, 7) have seen a decrease in the rate of opioid prescription, although the prevention of opioid addiction and overdose remains a significant public health priority (8).

Among the recommendations in these guidelines is that non-pharmacological treatments such as exercise, physical therapy, spinal manipulation, acupuncture and massage therapy (2, 9) be considered as primary treatment modalities for patients presenting with pain. Unfortunately, uptake of the recommendations from these guidelines has been slow. Further, whether these recommendations have impacted the rate of prescription of opioids for low back pain remains unknown. Two recent studies attempted to evaluate the use of opioid medication in the treatment of LBP, specifically the association between opioid use and chiropractic treatment for LBP. This review summarizes the results from these two studies and provides summary recommendations based on their conclusions.

Pertinent Results:

The studies in this review include a large, retrospective review of patients seen for new-onset low back pain (Kazis et al. – #1 above) and a systematic review and meta-analysis evaluating the association between chiropractic use and opioid receipt (Corcoran et al. – #2 above).

The retrospective study included a total of 216,504 participants who sought treatment from primary contact practitioners (physicians, chiropractors, physical therapists, etc.) for new-onset low back pain. The systematic review included 6 studies comparing opioid use in chiropractic users versus non-users treated for low back pain and included a total of 62,624 participants.

STUDY 1 – Kazis et al. (Retrospective Study):

53% of patients initially saw a primary care physician (PCP) for LBP. Among conservative treatment providers, chiropractors were the most commonly seen, accounting for 23.1% of patient visits. Of all patients, 18% received an opioid prescription within 3 days of their initial visit, 22% received a prescription within the first 30 days and 1.2% met the criteria for long-term use.

The type of practitioner seen was associated with early and long-term opioid use outcomes, with patients who initially saw a conservative practitioner having significantly decreased odds of both early and long-term opioid use when compared with those who first saw a PCP. The respective odds ratios (with 95% confidence intervals) for chiropractic care were 0.10 (0.09 to 0.10) for early use and 0.22 (018-0.26) long-term (this is a 90% lower chance acutely and a 78% lower chance long-term, by the way!); acupuncturist: 0.09 (0.07 to 0.12) early use and 0.07 (0.01-0.48) long-term; physical therapist: 0.15 (0.13 to 0.17) early use and 0.27 (0.15-0.48) long-term. Among those who saw a physician first, patients seen initially by an orthopaedic surgeon (0.63 [0.60-0.67]), neurosurgeon (0.58 [0.47-0.71]) and rehab physician (0.54 [0.49-0.59]) had a lower risk of opioid use as compared with PCPs in the short-term (early use), although patients seeing emergency room physicians for their first visit had an increased risk (OR 2.66 [95% CI 2.54-2.78]).

Corcoran et al. – Systematic Review and Meta-analysis:

The prevalence of chiropractic care ranged between 11.3% and 51.3% among eligible studies. Using a random-effects analysis, chiropractic users had 64% lower odds of receiving opioid prescriptions than did non-users (OR = 0.36 [95% CI: 0.30-0.43], p=0.001, I2=92.8%). This observation was consistent across all 6 eligible studies, with non-chiropractic-users prescribed opioids at rates ranging between 16% and 38.2% higher than chiropractic users.

Clinical Application & Conclusions:

Both studies summarized in this review concluded that patients who initially see chiropractors or other conservative practitioners for LBP are significantly less likely to receive a prescription for opioids when compared with those who see a primary care physician first. The fact that conservative practitioners are unable to prescribe opioid medications and the additional issue of health plan benefit structure – especially in the United States – are mentioned as confounding factors by both author groups; however, the results may indicate that the use of conservative treatment provides relief sufficient to avoid ultimately visiting a PCP for pharmacological treatment. More research is needed to determine the roles of the multiple factors influencing these decisions, but both of these papers contribute to the growing body of evidence suggesting that chiropractic care can help alleviate at least some of the burden of the growing opioid crisis!

Study Methods:

STUDY 1: Kazis LE, Ameli O, Rothendler J et al. Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open 2019; 9: e028633.
This was a retrospective study of patients seen by a healthcare provider for new-onset LBP and who were also opioid-naïve at their initial visit. The OptumLabs Data Warehouse was used to gather patient data for claims recorded between 2008 and 2013.

Exclusion criteria included a prior prescription for opioids within the 12 months prior to the index event, a diagnosis of neoplasm in this 12-month period or within 3 months of the index LBP event, or a diagnosis of LBP of a type that would typically not be amenable to conservative care.

Early opioid use was defined as an opioid fill within 30 days of the index visit while long-term use was an opioid fill within 60 days of the index date and either > 120 days opioid supply in a 12-month period or > 90 days supply with 10+ prescriptions over a 12-month period (5, 10).

Statistical analysis relied largely upon a multivariable logistic regression, with 2:1 propensity score matching used to balance patients who saw either a PCP, chiropractor or physical therapist as their initial practitioner.

STUDY 2: Corcoran KL, Bastian LA, Gunderson CG et al. Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis. Pain Medicine 2019; Sep 27. pii: pnz219. doi: 10.1093/pm/pnz219. [Epub ahead of print].
One clinical librarian searched the following databases: Medline, Embase, AMED, Web of Science, PubMed and CINAHL from inception to April 2018. Eligible studies include those with adult patients (> 18 years of age) with non-cancer pain and quantitatively reported opioid use amongst chiropractic users and non-users. Studies reporting on spinal manipulation delivered by practitioners other than chiropractors were excluded. Primary outcomes included opioid use among chiropractic users and non-users and the length of follow-up.

Methodological quality was assessed using the Newcastle-Ottawa Quality Assessment Scale (11). Data were extracted by 2 co-authors. Data pooling was performed using a random-effects model.

Study Strengths / Weaknesses:

Strengths:
  • Both studies included relevant comparisons between conservative practitioners and physicians.
  • The patient populations in both studies were substantial, providing higher confidence in the ability to apply their conclusions.
  • Pooled data in the meta-analysis strengthened the conclusions.
  • A comprehensive methodological quality assessment was completed in the systematic review (Corcoran et al.).
Weaknesses:
  • In the retrospective study (Kazis et al.), information was collected using claims data, which limits the generalizability of the results.
  • The severity of LBP was not reported in studies. As such, no conclusions can be made regarding whether differences existed between patients who sought out conservative care versus PCPs (in theory, those with more severe LBP may consult a PCP and may be more likely to need an opioid prescription).
  • Selection bias may have influenced both papers, as reasons for choosing conservative treatment were not discussed (for example, those who see a chiropractor may wish to avoid opioid prescription).

Additional References:

  1. Hughes A, Williams M, Lipari R. Prescription drug use and misuse in the United States: results from the 2015 national survey on drug use and health, 2016.
  2. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain--United States, 2016. JAMA 2016; 315.
  3. Shmagel A, Ngo L, Ensrud K, et al. Prescription medication use among community-based U.S. adults with chronic low back pain: a cross-sectional population based study. J Pain 2018; 19: 1104–12.
  4. Opioid Overdose [Internet]. Centers for disease control and prevention. centers for disease control and prevention, 2017. Available: https://www. cdc. gov/ drugoverdose/ data/ statedeaths. Html [Accessed cited 6 Nov 2018].
  5. Boudreau D, Von Korff M, Rutter CM, et al. Trends in De-facto longterm opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf 2009; 18: 1166–75.
  6. Bohnert ASB, Guy GP Jr, Losby JL. Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention’s 2016 opioid guideline. Ann Intern Med 2018; 169(6): 367–75.
  7. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Recomm Rep 2016; 65(1): 1–49.
  8. Alexander LM, Keahey D, Dixon K. Opioid use disorder: A public health emergency. JAAPA 2018; 31(10): 47–52.
  9. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain. Ann Intern Med 2017; 166.
  10. Elixhauser A, Steiner C, Harris DR, et al. Comorbidity measures for use with administrative data. Med Care 1998; 36: 8–27.
  11. Wells GS, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. Ottawa, Canada: Ottawa Hospital Research Institute; 2013. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. (accessed January 17, 2019).