A Chiropractic Response to Australia's Opioid Crisis
Lower back pain is the number one leading cause of disability worldwide. In Australia, it is the number one cause of early retirement, which subsequently leads to income poverty in many cases, reports the University of Sydney.1
Recent studies have demonstrated that an "overwhelming amount of research" reveals most pain medicines had little to no effect compared to placebos in treating lower back pain. GPs are now unlikely to recommend pain medicines in response to changes in major international guidelines for the management of lower back pain.
The UK National Institute for Health and Care Excellence clinical guideline for low-back pain and sciatica, and the American College of Physicians clinical practice guideline both encourage a shift in thinking about the primary care management of lower back pain.
The University of Sydney conducted a review into lower back pain which was published on Monday 13 November 2017. Dr Adrian Traegar, a lead author of the paper, said "These new guidelines suggest avoiding pain medicines initially and discouraging other invasive treatments such as injections and surgery. The recent changes to these guidelines are important and represent a substantial change in thinking on how best to manage LBP – the previous recommendations were in place for decades."2
Research published by Erin Krebs and the Minneapolis Veterans’ Health Care System in July 2017 found that opioids are no better than ibuprofen or paracetamol at reducing lower back pain over a 12-month period, yet these opioids came with the threat of dependence and addiction, which has been blamed for an increase in accidental overdoses.3
In November 2016, the Canadian Chiropractic Association (CCA) released their white paper, A Better Approach to Pain Management in Canada. The CCA’s white paper asserts that “the evidence is clear that manual therapies, including chiropractic, should be first-line options for the management of musculoskeletal conditions within the inter-professional healthcare team. Such management offers a safe, effective, non-invasive, coordinated, and cost-effective alternative to opioids”.4
Chiropractic focuses on the relationship between the spine and the nervous system, without the use of surgery or drugs. For chronic back problems, chiropractors use a variety of non-surgical treatments, such as spinal manipulation or manual therapies.
In recognition of the significant concerns around opioid use within the Australian community, the Chiropractors’ Association of Australia (National) commissioned a review for consideration by the profession to assist in the response to issues surrounding problems with opioid usage, particularly as it relates to the management of musculoskeletal disorders. It was not the intent of the review to provide a comprehensive analysis, but rather an overview of the issues and some activities in response to them.
These activities aim to inform and identify possible steps and solutions the chiropractic profession could offer, particularly within the context of current and proposed initiatives that involve regulated healthcare professions, and taking into account similar initiatives underway in other countries involving chiropractors and other musculoskeletally-focused professions. Key points include:
- Opioid use in Australia, and its impact on individuals and the community, is increasingly problematic and follows similar trends in North America
- The most effective response(s) by the chiropractic profession in Australia will differ from those in North America largely because of the different profiles for chiropractic within these countries, the scale of the opioid issue and different level of its recognition, and the varying government led initiatives underway
- Any response by the chiropractic profession to problematic opioid usage within Australia needs to be carefully considered to ensure that the profession is not seen to be making recommendations outside its competency
- The CAA believes the focus should be maintained on the efficacy of musculoskeletal interventions as a first line treatment for musculoskeletal disorders, with attention drawn to chiropractic’s musculoskeletal expertise, education, safety and high levels of patient satisfaction
- Understanding the scale of the problem is less important for the chiropractic profession than understanding that it is a significant, complex and growing issue, and that pain management for musculoskeletal conditions is a significant proportion of opioid use
- Chiropractors’ concern for and desire to improve health outcomes for the Australian community in collaboration with other health professions will be central to the broader messages to and from the profession
- The profession, in understanding its strengths and limitations, should be able to effectively inform the community of the option to seek chiropractors as a first-line option for musculoskeletal pain.
- Equally, it is important not to overstate chiropractic’s role. Chiropractors understand that the solutions to musculoskeletal problems can be complex and multi-faceted, and that is particularly true in this context. It is likely across many countries, including Australia, that addressing the issues will include numerous agencies and professionals, and focus on such things as: the illegal manufacture and supply of opioids; educating patients about the dangers of misuse; better tracking of prescription use; revising guidelines and educating doctors, pharmacists and other healthcare workers; research on treatment of opioid addiction; and of course, promoting alternatives to opioids (pharmaceutical and non-pharmaceutical).
- While the chiropractic profession has often cautioned against excessive use of pharmaceutical solutions when less invasive and functionally orientated solutions such as chiropractic are available, chiropractors should not overstate this in the context of the Australian healthcare system and broader community.
- The profession needs to effectively communicate the evidence for musculoskeletal interventions as an appropriate part of the solution for musculoskeletal problems; this includes the safety, efficacy and high patient satisfaction of chiropractic in this area.
- Demonstrating the profession’s appreciation of the complexity of the issues will be critical to effective collaboration and articulating the role chiropractic can play.
- While it is not the role of chiropractors to provide advice on prescription medicines (they should be referred for discussion between the prescriber and patient), it is important to be aware of their use and issues, as well as the care and management chiropractors can reasonably advocate they can provide.
- Chiropractic care may have a larger role and benefit than just pain relief, but pain relief is a significant part of the care chiropractors provide, particularly initially. Chiropractors are well-educated, effective and low risk musculoskeletal experts who may be an excellent use of resources and who have a readiness to support good patient outcomes.
With this review now complete, CAA are currently strategising the best way to disseminate this to the relevant stakeholders and ensure the recommended follow-up activities are followed.
- Adrian Traeger, Rachelle Buchbinder, Ian Harris, and Chris Maher Diagnosis and management of low-back pain in primary care CMAJ November 13, 2017 189:E1386-E1395;
- Landmark Trial Punctures the Myth That Opioids Provide Powerful Relief of Chronic Pain The Back Letter: July 2017 - Volume 32 - Issue 7 - p 73–81 doi: 10.1097/01.BACK.0000520970.46118.bc
- Canadian Chiropractic Association, A Better Approach to Pain Management Responding to Canada’s Opioid Crisis, November 2016