Articles by JCS

Attack of Opioids

                                                                                                   

Word Count: 2778

The Attack of Opioids

There is a new plague sweeping America and the world killing over 100,000 people annually. Unlike the old infectious epidemics such as malaria, smallpox, Spanish Flu and tuberculosis or new ones like the Ebola virus in West Africa that resulted in 11,315 deaths,[1] today we have a modern plague dubbed “Pharmagedon” wreaking havoc not from natural contagions, nor is this new plague caused by illicit drugs such as cocaine, methamphetamines, crack or marijuana, although these recreational drugs are addictive and possibly deadly.

Today the biggest fear stems from prescription painkillers. In 2014, the CDC revealed in its shocking study, “Opioid Painkiller Prescribing”,[2] that MDs prescribed 259 million prescriptions for opioids, equivalent to one for every American adult.[3] Overdose deaths, including both OPR and heroin, hit record levels in 2014, with an alarming 14 percent increase in just one year.

Increases in opioid prescription painkillers are the biggest driver of the drug overdose epidemic. There were over 47,055 overdose deaths reported in 2014, which equates to 128 deaths each day. According to the CDC’s data published in CDC’s Morbidity and Mortality Weekly Report,[4] from 2000 to 2014 nearly half a million Americans died from drug overdoses. In 2014, there were approximately one and a half times more drug overdose deaths in the United States than deaths from motor vehicle crashes.[5]

The CDC also reported 61% of all overdose deaths, a record 28,647 in 2014 or 78 people a day, were from prescription synthetic opioids such as OxyContin, Percocet, Hydrocodone or Vicodin, and natural opiates like heroin.[6] The most commonly prescribed opioid pain relievers, oxycodone and hydrocodone, continue to be involved in more overdose deaths than any other opioid type.

“The increasing number of deaths from opioid overdose is alarming,” said CDC Director Tom Frieden, M.D., M.P.H. “The opioid epidemic is devastating American families and communities. Frieden admitted that MDs had essentially replaced street corner drug pushers as the most important suppliers of illicit narcotics.[7] Ironically, by using an MD instead of a street pusher, this drug deal is perfectly legal and paid by health insurance.

The CDC’s findings show that two distinct but intertwined trends are driving America’s overdose epidemic: a 15-year increase in deaths from prescription opioid pain reliever overdoses as a result of misuse and abuse, and a recent surge in illicit drug overdoses driven mainly by heroin. Both of these trends worsened in 2014.

According to the National Institute on Drug Abuse, the U.S. accounts for only 5 percent of the world's population, yet Americans consume at least 75 percent of all OPR doled out by MDs.[8] In 2011 to 2012, over 13 million American adults used OPR and two million U.S. residents either abuse opioids or were addicted to them.[9] Opioid use disorders resulted in 51,000 worldwide deaths in 2013, up from 18,000 deaths in 1990.[10]

Let’s put this into perspective: 128 daily overdose deaths (and 78 die from opioids alone), is equivalent to the 130 deaths when Islamic terrorists attacked Paris on the evening of November 13, 2015, but the deaths from prescription drugs happen every day in America and goes with little fanfare in the media.

However, if Islamic terrorists were killing 128 Americans daily in our country, there would be a huge public uproar, Congress would be up in arms rattling its swords calling for military action, and the media would be swarming for a scapegoat to blame.

There appears to be reluctance by the media to accuse medical professionals for promiscuous prescribing or blame Big Pharma, one of the media’s biggest sponsors, for manufacturing these dangerous drugs laced with heroin; most often the news accounts blame the victims as abusers.

The most commonly prescribed OPR, those classified as natural or semi-synthetic opioids such as oxycodone and hydrocodone, continue to be involved in more overdose deaths than any other opioid type. Originally OPR were used appropriately for post-surgical or cancer cases with intractable pain. Today the majority of prescription OPR is taken for chronic low back pain[11], and many are abused recreationally just to get high due to the addictive nature of these heroin-laced pain relievers.

Washington Awakens

Finally numerous federal agencies have examined the issues of the growing OPR problem after thousands of Americans have needlessly died, become disabled or addicted to narcotic painkillers prescribed by medical physicians.

Here are a few of the major studies:

  • Institute of Medicine (IOM): “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,”[12] 2011.
  • National Institutes of Health: Report of the Task Force on Research Standards for Chronic Low Back Pain, 2014.[13]
  • Office of the Army Surgeon General: Pain Management Task Force; Final Report, May 2010.[14]
  • VA/DoD: Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, 2009.[15]
  • Health and Human Services: National Pain Strategy: “A Comprehensive Population Health-Level Strategy for Pain,” 2015.[16] 
  • National Institute on Drug Abuse:America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,” 2014. [17]
  • Centers for Disease Control: Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.[18]

The conclusion of each study was very similar:

  • too many opioids,
  • too many promiscuous prescribers,
  • general physicians uneducated in chronic pain management, and
  • the need for nondrug alternatives for care.

The National Pain Strategy (NPS)[19] best summarized this pandemic of pain and ineffective medical care:

The Problem: The high prevalence of pain across the population and its impact on individuals and families creates a significant responsibility for health care professionals.

  • Despite the need to address this public health problem, many health professionals, especially physicians, are not adequately prepared and require greater knowledge and skills…
  • Education and training of health professionals…is insufficient, in part because educators lack access to valid information about pain and pain care.
  • As a result, practitioners may rely primarily on procedural or pharmacological approaches that alone are not effective and may have significant unintended adverse consequences such as addiction and medication misuse for which many health care providers lack skills and knowledge to identify and manage…
  • Change cultural attitudes about chronic pain, debunking stereotypes and myths related to people with chronic pain and various pain treatment options and emphasizing the value of pain self-management programs in enabling people to live better with chronic pain.

Although these points by National Pain Strategy were spot on (although years late), there are other factors and omissions that were obvious to those already fighting in the battle against chronic pain.

Indeed, it appears this NPS may be “too little, too late” considering the horses are already out of the barn and Big Pharma and the AMA have shown no intention to reign them in; as to be expected, they have fought the recommendations of the CDC guideline to control this problem.

Although the NPS did admit the inadequacy of medical education in pain care and the insufficient training of MDs in pain management, inexplicably the NPS suggests to use MDs as the portal of entry: 

 While most pain care would be coordinated by primary care practitioners, specialists would be involved judiciously in the care of patients who have increased co-morbidities, complexity, or risk.[20]

The NPS recommendation is dumbfounding if not totally shocking considering the circumstances of this OPR abuse. In his article, “Why Should the National Pain Strategy Be MD-Centric?”, Editor  Mark Schoene, associate editor of an international spine research journal, The BackLetter, also commented on the buffoonery proposed by the NPS to use MDs as the portal of entry for chronic pain patients considering they created this epidemic in the first place:

The draft report of the National Pain Strategy mentions the services of chiropractors and complementary/alternative providers—who play such a prominent role in the management of low back pain in the U.S. (They account for as many as 50% of back care visits.)

However, the report envisages a future where primary care physicians and pain specialists will play the most prominent roles in the prevention and management of chronic pain. Regarding low back pain, at least, this may not be a balanced and realistic view. It may exaggerate the capabilities of both primary care physicians and pain specialists—and downplay the potential contributions of other health professionals.

Primary care physicians and pain specialists don’t have unimpeachable backgrounds in the management of chronic pain in the U.S. These are the medical professions primarily responsible for the opioid overtreatment crisis. Are the two professions that helped create the worst pain management crisis in history of modern medicine capable of leading the way forward? That remains to be seen.[21]

The NPS also admits MDs need more education:

Physicians are not adequately prepared and require greater knowledge and skills to contribute to the cultural transformation in the perception and treatment of people with pain.”

Unfortunately, a weekend CME seminar will not adequately prepare an MD nor compare to the existing education of chiropractors. Most of all, such superficial preparation will certainly not achieve the required skill level to render chiropractic care or any CAM treatment for chronic pain. Dr. Scott Haldeman, MD, DC, PhD, suggests 12 months’ full time training in spinal manipulative therapy following a medical degree would be appropriate to become knowledgeable of this treatment.[22]

Manipulation Matters

Mark Schoene warned of this Pharmagedon stemming from opioids for back pain:

“There is now an overwhelming body of evidence that excessive prescription of opioids has triggered a wave of addiction, injury, and death across American society—one that will likely batter U.S. communities for decades.

There is an urgent need to restrain the routine prescription of opioids for common noncancer pain conditions—and especially chronic low back pain. There is no evidence that they are an effective long-term treatment. And their risks are obvious.”[23]

This is where chiropractic enters to fight this attack of opioids. Research now shows for the majority of people their main complaints are musculoskeletal disorders (MSD) causing chronic pain. This point was made clear in a 2009 study, “Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain,”[24] that found opioid users mainly suffered from the following MSDs:

1. Back pain                             29.9%        

2. Extremity pain                      22.6%

3. Osteoarthritis                       11.1%

4. Fractures, contusions            6.4%

5. Neck pain                                5.2%

6. Headache                               4.1%

The majority of these MSD complaints stem from joint problems, which is the chiropractic paradigm for chronic pain and a concept rarely told to the suffering patients by MDs. Until a patient steps into a chiropractic office, they have never been explained why manipulation to restore proper joint play works so well to alleviate chronic pain caused by joint dysfunction.

This is the factor in this pain formula the public, press, and NPS panelists need to learn. Although it is generally understood the human musculoskeletal system consists of 640 muscles and 206 bones exist in the human body, people do not realize there are 516 joints throughout the body.

Specifically in the spinal column, most people know there are 24 vertebrae connected by 23 discs, but few realize the spine has joints. Counting all the vertebral joints, sacroiliac joints, rib heads, and the pubic symphysis, new research now suggest the total is 361, a fact lost to most physicians and certainly the public. This total includes all synovial, symphysis and syndesmosis joints according to Gregory D. Cramer, DC, PhD, Dean of Research at National University of Health Sciences.[25]

Considering the vast number of joints in the body and the precarious nature of the weight-bearing spine pillar, it is logical that manipulative therapy is a viable nondrug treatment for many of these mechanical conditions, especially for back, neck, cervicogenic headache and extremity pain. Except for “fractures, contusions”, the other ailments often amendable to manipulation constitute 72.9% of all the opioid therapy used, which means the potential to help this quiet epidemic of chronic pain via manipulative therapy is enormous.

If just 50 percent of these chronic pain cases could be helped via chiropractic care that would greatly reduce costs, disability, addictions and deaths. In a TIME article, “Is There a Method to Manipulation?” reporter Andrew Purvis concluded, “If spinal manipulation could ease even a fraction of that financial burden, remaining skeptics might be forced to stifle their misgivings or get cracking themselves.”[26]

180 Degrees

If the NPS panelists had done their homework and followed evidence-based “best practices” guidelines, they would have known chiropractic care and other complementary/alternative (CAM) treatments were recommended by the Joint Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain published by the American College of Physicians and the American Pain Society:

Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation. [27]

Undoubtedly the most shocking recommendation of CAM providers were also heralded recently by the most politically powerful medical organization in the U.S. The Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations, is recognized nationwide as a symbol of quality and sets the standards that must meet certain performance standards or else risk losing accreditation.

The Joint Commission is a private, not for profit organization established in 1951 to evaluate health care organizations that voluntarily seek accreditation. The Joint Commission evaluates and accredits more than 16,000 health care organizations in the United States, including 4,400 hospitals, more than 3,900 home care entities, and over 7,000 other health care organizations that provide behavioral health care, laboratory, ambulatory care, and long term care services. The Joint Commission also evaluates and accredits health plans and health care networks.[28]

In a revolutionary decree as of January 2016, the Joint Commission updated its evidence-based guideline on pain management:

 Rationale for PC.01.02.07 [New for ambulatory care and office-based surgery practice]

The identification and management of pain is an important component of patient-centered care. Patients can expect that their health care providers will involve them in their assessment and management of pain. Both pharmacologic and nonpharmacologic strategies have a role in the management of pain.

The following examples are not exhaustive, but strategies may include the following:

  • · Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy
  • · Pharmacologic strategies: nonopioid, opioid, and adjuvant analgesics

Treatment strategies for pain may include pharmacologic and nonpharmacologic approaches. Strategies should reflect a patient-centered approach and consider the patient’s current presentation, the health care providers’ clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse. [29]

One needs to appreciate the irony of this new ruling by the Joint Commission. This is a complete reversal from its original position on chiropractors as trial evidence revealed at the Wilk v. AMA antitrust trial litigated by Mr. George McAndrews.

In 1962 when the medical war against chiropractors was formerly announced by the AMA’s Committee on Quackery to “contain and eliminate the chiropractic profession,” the AMA used its influence to persuade the Joint Commission to make “The Principles of Medical Ethics” a part of its Standards for accreditation of hospitals in order to ban chiropractors.

Member hospitals and physicians were prohibited from all forms of exchange with chiropractors, most importantly, referring to or accepting referrals from medical doctors – a professional courtesy common among ethical practitioners who referred to chiropractors seeking the best care for their patients.

Moreover, the punishment was severe: a hospital could be closed if it lost the Joint Commission’s accreditation. An individual physician could lose hospital privileges and be deemed unethical if found working with a chiropractor. A hospital itself could run the risk of losing accreditation if medical staff gave assistance or consulted with a chiropractor. Essentially chiropractors were branded taboo to physicians and hospitals alike.[30]

In this light, the Joint Commission’s new 2016 ruling on pain management was a 180 degree change in policy and speaks volumes about the importance to seek nondrug solutions to chronic pain and OPR abuse, even if it means recommending the once scorned but now vindicated chiropractors.

Hopefully as the American healthcare system implements “best practices” supported by evidence rather than politics, the benefits of chiropractic as the most clinically and cost-effective treatment for the pandemic of chronic pain may finally take place. After all, it’s only taken 54 years for this revelation to be recognized by the Joint Commission.

The pandemic of chronic pain and opioid misuse along with the Joint Commission’s policy revision to include chiropractic care may be the chiropractic profession’s foot into the door of the medical establishment to fight the Pharmagedon of opioid abuse.

(This article is an excerpt from JC Smith’s upcoming book, The Media War Against Chiropractors.)



[2] National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, www.cdc.gov/vitalsigns/, July 2014.

[4] Drug overdose deaths hit record numbers in 2014, CDC Newsroom Releases,  December 18, 2015

[5] CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2015. Available at http://wonder.cdc.gov.

[7] Centers for Disease Control and Prevention Press Release, CDC Vital Signs: Overdose of Prescription OPR—United States, 1999-2008; 2011: www.cdc.gov/media/releases/2011/t1101_presecription_pain_relievers.html.

[8] Opioid painkillers used in dangerous combinations, CBS News, December 9, 2014,

[9] BackLetter:

February 2016 - Volume 31 - Issue 2 - p 17 doi: 10.1097/01.BACK.0000480371.70730.19

[11] Denise Boudreau, PhD, Michael Von Korff, ScD, Carolyn M. Rutter, PhD, Kathleen Saunders, G. Thomas Ray, Mark D. Sullivan, MD, PhD, Cynthia Campbell, PhD, Joseph O. Merrill, MD, MPH, Michael J. Silverberg, PhD, MPH, Caleb Banta-Green, and Constance Weisner, DrPH, MSW. “Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain,” Pharmacoepidemiol Drug Saf. 2009 December ; 18(12): 1166–1175. doi:10.1002/pds.1833.

[21] Why Should the National Pain Strategy Be MD-Centric? BackLetter: February 2016 - Volume 31 - Issue 2 - p 16

[22] Ingles, BD, Fraser, B, Penfold, BR, Chiropractic in New Zealand, Report of the Commission of Inquiry into Chiropractic,  PD Hasselberg, Government Printer, Wellington, New Zealand. 1979, 43-44

[23] Are U.S. Physicians Focusing on the Wrong Aspect of Chronic Low Back Pain? BackLetter: February 2016 - Volume 31 - Issue 2 - p 13–21

[24] Denise Boudreau, PhD, Michael Von Korff, ScD, Carolyn M. Rutter, PhD, Kathleen Saunders, G. Thomas Ray, Mark D. Sullivan, MD, PhD, Cynthia Campbell, PhD, Joseph O. Merrill, MD, MPH, Michael J. Silverberg, PhD, MPH, Caleb Banta-Green, and Constance Weisner, DrPH, MSW. “Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain,” Pharmacoepidemiol Drug Saf. 2009 December ; 18(12): 1166–1175. doi:10.1002/pds.1833.

[25] Cramer, G.; Darby, S. 2014 Clinical anatomy of the spine, spinal cord, and ANS. 3rd Edition, Elsevier/Mosby, St. Louis, 559 illustrations, 672pp. Appendix I, pp. 638-642.

[26] Andrew Purvis, “Is There a Method to Manipulation?” TIME magazine, Sept. 23, 1991.  

[27]  R Chou, et al., “Diagnosis and Treatment of Low Back Pain:  A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society,” Low Back Pain Guidelines Panel, Annals of Internal Medicine 2 147/7 (October 2007):478-491

[28] http://healthfinder.gov/FindServices/Organizations/Organization.aspx?code=HR1458

[30] George McAndrews closing argument, Wilk v. AMA, p. 69.


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