THE OCTOBER 2015 NATIONAL CHIROPRACTIC HEALTH MONTH NCHM THEME OF #PAINFREENATION is incredibly pertinent to today’s back pain market and especially medical integration. Unfortunately, the first approach to managing back pain too often is medications, and the go-to choice is typically NSAIDs. With all of the negative press toward many common back pain medication choices, chiropractic physicians have an opportunity to seize a much needed educational role building the case for conservative care first in place of these medications.
The first line of treatment with medications tends to be the following order:
1 Acetaminophen, proven to be ineffective (BMJ 2015) and one most patients have already tried prior to seeking care.
2 NSAIDs, which can cause GI and CV symptoms. (Black box warning for both prescription and OTC forms)
3 Opioids, which come with serious warnings for misuse and addiction. (Black box warning for extended release and growing pressure for this warning to be extended to immediate release forms)
4 Off-label use of SSRI antidepressants, which have become preferred to tricyclic antidepressants because they have fewer side effects, even though they have inconsistent results. (Psychiatry 2008) Some doctors may prescribe SSRIs prior to opioids.
With this, we see why NSAIDs have long been a first choice for managing back pain, but they have been under increasing fire in recent years for the cardiovascular risks that studies have linked them to. The first of many strong warnings came in 2007 with the American Heart Association’s scientific statement on prescription NSAIDs, which focused especially on chronic musculoskeletal disorders. This warning recommended that patients with, or at risk of cardiovascular disease, attempt to control pain with a non-pharmacological approach. (Circulation, 2007)
A significant number of Americans fit into this risk category, and yet NSAID usage did not slow down, perhaps in an indication of the difficulty faced by many primary care physicians who manage these patients with limited options, where the quality of life for patients living with chronic pain becomes the primary treatment goal. The warnings for NSAIDs continue, translating to over-the-counter NSAIDs as well.
One Medication for Another
Because of these warnings, some MDs switched patients to opioids or antidepressants to control pain. Whether or not the rise of opioid addictions that hit communities in America is related to NSAID concerns, it’s clear that opioids are not the solution for the majority, especially when risk, but not efficacy, is clearly established (J. Pain 2013). Narcotic-based prescriptions are a difficult issue for MDs, as indicated in my article with Advocate Illinois Masonic Medical Center’s Neurosciences Institute, which quoted a pain medication specialist doctor, who stated, “I shiver and shake when patients come in requesting narcotic-based analgesics.” (See “Integration: A Conversation With the Neuroscience Institute,” ACA News, Oct. 2013, Page 30.)
In July 2015, the FDA again strengthened its warning for NSAIDs, indicating that harm can happen within the first few weeks and extending the warning to include any person taking the medication regardless of CV risk status. It’s been further identified that the greater the dosage, the greater the risk. These factors create a very real need for a safer therapy to control pain, which has resulted in a real opportunity for doctors of chiropractic (DCs) who wish to build medical referral relationships.
What’s frustrating for many DCs is knowing the positive impact on pain that can be made for patients — especially those suffering with chronic back pain, many of whom instead are treated with pain medications both short-and long-term. The guidelines acknowledge the benefits of manipulation, indicating its use to manage acute back pain, and for chronic pain, manipulation is listed alongside medications and other therapies such as PT. (Chou 2007). Yet, many DCs remain outside of the medical circle. With new health care laws and regulations, there is a very urgent need for DCs to secure our place as part of an integrated team.
Use NCHM to Educate MDs
However, if the medical community is unaware of chiropractic outcomes on pain, we can’t expect much change to happen in the form of referrals and enhanced patient access. This continued exclusion can’t possibly be good for our future, and sitting on the sidelines of health care cannot be an option. Thus, NCHM provides a very pointed opportunity for all DCs to leverage ACA marketing and educational materials to educate the MDs in your community.
Marketing to MDs is about understanding needs, and any MD who prescribes NSAIDs, opioids or any other medication for back pain is trying to control the pain cycle and enhance patient quality of life. This need also extends to subspecialities, such as geriatrics, where many MDs favor opioids over NSAIDs because of the significant risk of cardiovascular disease, which develops as sequelae from renal impairment in this at-risk population. (Drugs, 2003)
Chiropractic physicians fill a very specialized role for a huge segment of the back pain market share in meeting the need to offer a conservative alternative to medications in all appropriate patients, through trials of evidence-based health care that includes manipulation, before settling on long-term medication management. The earlier the intervention, the better. The doctors in your community understand the dangers of medication and they want another solution, but you must present the solution and help meet that need.
There are certainly talking points to address pain management that include manipulation, but also strengthening exercises, modifiable risk factors such as weight management, exercise, smoking, diet and other alternative treatments that you can offer patients. Tying this message in, alongside a desire to help physicians limit the time and dosage of any medication, is certainly a solution to their current pain management options. These points, when combined, help create a sense of urgency for rethinking available treatment options.
While manipulation alone may not be a substitute for medication in treating more severe pain, it could certainly be reasonable to suggest that if manipulation proves to be effective for a patient, then the amount, dosage and length of time on a given medication could be reduced. Taking the stance that an integrated, two-pronged approach could offer these patients the most effective and safest form of care is in line with both warnings and research.
It’s also important to share your desire to work as part of a team, through provider collaboration, to establish a reasonable and sequential approach to managing back pain that reduces redundant care, patient self-navigation and overall costs. Be prepared for a discussion on the safety of medication that may bring up concerns over the safety of manipulation.
In addition to approaching standard medical doctors, think outside the box by reaching out to addiction specialists. They manage patients who have addictions and pain, and they are very open to non-medication forms of care. Another option might be to work with your local county’s health services, many of which have opioid addiction departments and community outreach programs. Any opportunity that places you and our profession as a tangible solution will enhance our profession’s overall inclusion.
Your conversations help not only your own personal practice growth but those of our community as well.
While manipulation alone may not be a substitute for medication in treating more severe pain, it could certainly be reasonable to suggest that if manipulation proves to be effective for a patient, then the amount, dosage and length of time on a given medication could be reduced.
Dr. Christina Acampora is the founder of Aligned Methods, which offers online medical marketing courses and resources, and is the author of Marketing Chiropractic to Medical Practices, a 2007 Jones and Bartlett publication. She speaks for chiropractic and university organizations and is a consistent contributor for ACA News. She can be reached at www.alignedmethods.com.