Articles by JCS

CDC Snubs DCs

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CDC Snubs DCs

                              "Opioids do not kill pain. They kill people,"                                

Donald Teater, MD, National Safety Council

With much fanfare in the national news media, on March 15, 2016, the Centers for Disease Control and Prevention (CDC) issued its awaited “Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.” Twelve recommendations were given in an attempt to rein in the flood of prescription opioid painkillers flowing from medical offices.

However, the CDC report was also a letdown for many reasons despite its heroic attempt to ward off the attack of opioids by Big Pharma and its thousands of medical vendors.

The most notable reasons were:

  • The guideline is totally voluntary.
  • No blame placed on Big Pharma or MDs for the rise of opioids.
  • The guideline remains MD-centric despite the fact MDs caused this Pharmageddon in the first place.
  • No mention of chiropractic care as a nondrug solution.
  • No removal of MDs as POE for MSDs.

Another important factor forgotten by the CDC was the concept of “Prevention” as stated in its own moniker. Inexplicably, the CDC focused mainly on alternative nonopioid drugs rather than on preventative measures and alternatives to opioid use. Of course, at the top of the list for chronic pain would be the chiropractic profession.

It is estimated that more than 100 million people suffer from chronic pain in this country, and for those suffering from cancer, burns, post-surgical or the terminally ill, opioid therapy may be appropriate.[1]

However, the majority of American patients seek relief from persistent, moderate-to-severe low back pain (approximately 38 million), osteoarthritis (approximately 17 million), and other musculoskeletal conditions like neck pain that respond well to nondrug chiropractic care and other CAM therapies.[2]

Considering the magnitude of low back pain, the obvious question begs to be asked: how can any consensus on nonopioid treatments for chronic pain not include the leading nondrug profession that deals directly with chronic back pain – the chiropractic profession?

Doctor-Driven Epidemic

Clearly there are many more problems than answers in the CDC Guideline beginning with the realization the CDC is a toothless tiger that is also blind to the fact MDs are inept in the management of chronic pain have led to this opioid disaster.

This revelation is not new information to CDC Director Tom Frieden who admits, "The prescription overdose epidemic is doctor-driven." Yet, he somehow assumes, "It can be reversed in part by doctors' actions."[3] That is certainly a leap of faith by Dr. Frieden since these promiscuous prescribers have shown little effort to restrain themselves for the past twenty years.

The CDC noted in its guideline the enormity of this opioid war: “In 2012, health care providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills.”[4] In this light, it is odd that Dr. Frieden believes this prescription overdose epidemic can be reversed voluntarily by the very culprits responsible for this huge narcotic epidemic.

Dr. Frieden’s optimism is equivalent to assuming “El Chapo” will suddenly see the light and stop distributing street drugs in America. Indeed, what motivation does “Dr. Chapo” and Big Pharma have to cooperate? Doling out opioid prescriptions like Halloween candy is easy money evident by the fact the original opioid painkiller, OxyContin, manufactured by Perdue Pharma, has earned more than $27 billion since its introduction in 1996.[5]

To the astonishment of many addiction professionals, the FDA is also complicit in this narcotic scandal with its approval of OxyContin for kids in 2014.[6] This nonsense comes at a time when one in five high school students already abuse painkillers with 2,500 additional teenagers starting every day, according to results from the National Survey on Drug Use and Health. Almost 50% of teens believe that prescription drugs are much safer than illegal street drugs and 60% to 70% say home medicine cabinets are their source of drugs.[7]

The FDA also approved another new opioid product, Zohydro, in easily crushed capsules that contain up to 50 milligrams of pure hydrocodone; that’s 10 times more hydrocodone than a regular Vicodin. One capsule is enough hydrocodone to kill a child. An adult lacking a tolerance to opioids could overdose from taking just two capsules.[8]

This FDA nonsense illustrates why America is losing the war on opioids. Seriously, how can the toothless CDC fight the medical industrial complex consisting of Big Pharma, the insurance companies, the AMA, and the FDA in this war against opioids?

Smoke & Medical Mirrors

The failure to mention the incompetence of MDs was another glaring oversight by this CDC Guideline. In effect, a patient seeking advice from an MD about chronic back pain is as doubtful as asking their dentist.

It is well established musculoskeletal disorders are outside the scope of medical training and practice and this lack of skill has led to the biggest narcotic outbreak in the history of this country as the quick-fix for pain control.

Researcher Richard Deyo, MD, MPH, author of “Watch Your Back!”, also mentioned the problems with medical treatments and physician incompetence in diagnosis and treatment of low back treatments:

"Calling a [medical] physician a back pain expert, therefore, is perhaps faint praise — medicine has at best a limited understanding of the condition. In fact, medicine's reliance on outdated ideas may have actually contributed to the problem."[9]

Studies confirm most primary care physicians are inept in their training on musculoskeletal disorders,[10] more likely to ignore recent guidelines[11], more likely to suggest spine surgery than surgeons themselves,[12] and they are the easiest source of opioid painkillers.[13]

The prominent spine journalist, Mark Schoene, editor of an international spine research journal, also questions the buffoonery to use MDs as the portal of entry for chronic pain patients considering they created this opioid epidemic in the first place:

“Primary care physicians and pain specialists…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.”[14]

As more proof of the non-compliant practices by MDs, a recent survey of 200 doctors conducted by the National Safety Council found 99% of them wrote prescriptions that exceed the CDC’s recommended three-day dosage limit with nearly one-quarter giving out month-long dosages.[15]

74 percent of doctors believe pain relief is best achieved by offering patients opioids: morphine or oxycodone (OxyContin), although experts from the Safety Council noted that over-the-counter pain relievers (including ibuprofen and acetaminophen) were more effective at providing short-term pain relief.

More medical malpractice seems to be at play particularly when addressing back pain and dental pain. 71% and 55% of doctors say they prescribe opioids for back pain and dental pain, respectively; however, these drugs were not considered the ideal treatment for either condition according to the Safety Council.

Indeed, the ideal treatment for back pain is chiropractic care and dentistry for dental pain. It doesn’t take a rocket scientist to know that, but this is more evidence the opioid epidemic will not stop as long as MDs are the portal of entry for chronic pain patients and doling out opioids for every pain patient.

Donald Teater, MD, a medical advisor at the National Safety Council bluntly stated this problem. "Opioids do not kill pain. They kill people. Doctors are well-intentioned and want to help their patients, but these findings are further proof that we need more education and training if we want to treat pain most effectively."

The Forgotten Answer

Obviously America needs better help for these pain patients, but instead of the inept MDs and toothless recommendations in the CDC guideline, the best solution for the majority of chronic pain patients is the chiropractic profession.

Research shows the main complaints for the majority of people with chronic pain using opioid painkillers are musculoskeletal disorders (MSD). This point was made clear in a 2009 study, “Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain,”[16] 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%

This is where the chiropractic profession enters into this pain equation. Undoubtedly the largest illusion concerning chronic back pain specifically and musculoskeletal disorders in general is the lack of understanding that many of these chronic conditions are mechanical problems in the musculoskeletal system, which is known as “joint dysfunction” in orthopedic terminology, aka, in chiropractic parlance as the “vertebral subluxation” and in osteopathic lexicon as the “spinal lesion.”

The concept of “non-specific mechanical back pain” is not new, just ignored by a medical profession hell-bent on prescribing opioid painkillers, rendering epidural steroid injections and, ultimately, railroading patients into unnecessary back surgery based on the “bad disc” diagnosis, now an ‘urban legend’ in medicine.

The Mayo Clinic systematic review confirmed disc degeneration is present in high proportions of asymptomatic individuals, increasing with age, and are likely part of normal aging and unassociated with pain, yet thousands of patients fall prey to fusion surgery who are mistakenly diagnosed with “bad discs.”[17]

Editor Schoene remarked about the myths in medical spine care:

“Although most patients don’t recognize it, the U.S. medical system offers back care that is out of sync with modern standards — and out of line with the scientific evidence… This is a classic example of looking at a treatment through rose-colored glasses.”[18]

Instead of looking at back pain from the perspective of “bad discs,” the mechanical explanation accounts for most chronic pain. In a quick review, counting all the vertebral joints, sacroiliac joints, rib heads, and the pubic symphysis, research now suggests the total number of spinal joints 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.[19]

Just before his death in 1992, John McMillan Mennell, MD, MRCS, LRCP, published his book, The Musculoskeletal System: Differential Diagnosis from Symptoms and Physical Signs, in which he described the logic of joint dysfunction as a cause of pain and joint manipulation as the only correction:

“Loss of play in synovial joints is mechanical diagnostic entity designated ‘joint dysfunction,’ and this is a mechanical diagnosis of a cause of symptoms. It is common in any synovial joint anywhere in the system. To correct a mechanical fault it is logical to seek a mechanical form of treatment. This is joint manipulation.”[20]

Considering there are 516 joints in the entire body, it becomes clear why joint problems are commonplace and why “hands-on” techniques to restore joint play are so effective for many of the musculoskeletal disorders mistakenly treated with opioid medications.

Elephant @ CDC

Apparently the CDC is not only toothless and blind to the research supporting nondrug manual therapies, it is also mute. A simple word search will discover the entire CDC guideline fails to mention the word “chiropractic” or “manipulation” in its report. This omission is perhaps indicative of the medical bias at the CDC that ignores the prevailing evidence for chiropractic care and a mechanical explanation for chronic pain.

For your review, here is the link to the CDC Guideline on “NONOPIOID TREATMENTS FOR CHRONIC PAIN.” In the section, “Recommended Treatments for Common Chronic Pain Conditions,” you can read the vague recommendations for Low Back Pain:

  • Self-care and education in all patients; advise patients to remain active and limit bed rest.

Nonpharmacological treatments:

  • Exercise, cognitive behavioral therapy, interdisciplinary rehabilitation

Medications:

  • First line: acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs)
  • Second line: Serotonin and norepinephrine reuptake inhibitors (SNRIs)/tricyclic antidepressants (TCAs)

As you can read, there is no mention of chiropractic by name or spinal manipulation. The same omission of any “hands-on” manual therapies treatments was evident in the CDC Alternative Treatments for Migraine, Neuropathic Pain, Fibromyalgia, and Osteoarthritis. Principally the main alternatives mentioned were nonopioid medications and other adjunctive therapies weakly supported by evidence.

One has to question the objectivity of the CDC Guideline considering the volume of evidence ignored. Strangely omitted in Alternative Treatments was any mention of chiropractic care despite its high standing among federal guidelines[21],[22] and patient surveys in Medicare[23], TRICARE[24], Consumer Reports[25], and Gallup polls.[26],[27]

The irony of the CDC Guideline is obvious: chronic low back pain is the leading reason for opioid use[28] and chiropractic care has long been regarded as the leading nondrug treatment for this pandemic of back pain. No one familiar with the evidence will argue that point, unless they suffer from professional amnesia or harbor medical bias about chiropractors foisted by the AMA’s propaganda.

Once again, there was no mention of the third-largest, physician-level profession offering the most effective treatment for chronic pain – chiropractic care. Apparently chiropractic is the proverbial “elephant in the room” at the CDC and among news organizations.

Official Recognition

Despite the CDC’s blindness, many medical guidelines now endorse spinal manipulation, the mainstay of chiropractic care for over a century.

Indeed, the value of this brand of nondrug care is not a new revelation considering the Agency for Health Care Policy and Research declared “spinal manipulation” a “proven treatment” for low back pain over twenty years ago in 1994[29], two years before Perdue Pharma introduced OxyContin. This 22-year federal guideline was subsequently ignored by a medical profession hell-bent on drugging patients with painkillers and performing spine fusions instead of referring to DCs as the guideline suggests.

In 2007, the American College of Physicians and the American Pain Society in the Joint Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain also recommended chiropractic care and other complementary/alternative (CAM) treatments:

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. [30]

Another landmark decision was announced January, 2015, by the Joint Commission, the national accreditation body for all hospitals and health organizations. An updated evidence-based guideline on pain management also included chiropractic among the nondrug strategies:

Rationale for PC.01.02.07

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.[31]

One needs to understand the history of the Joint Commission to appreciate this policy change. In 1963, at the urging of the AMA in its medical war to “contain and eliminate the chiropractic profession,”[32] the Joint Commission enforced the AMA’s illegal boycott of chiropractors from hospitals with the threat of loss of accreditation.

Obviously this new ruling by the Joint Commission endorsing “chiropractic therapy” by name is a 180 degree change in policy and speaks volumes about the importance to seek nondrug solutions to chronic pain and opioid painkiller abuse, even if it means recommending the once-scorned chiropractors.

CDC Bias

With these recommendations in mind, the omission of chiropractic care in the CDC Guideline begs to question the make-up and bias of the panel of experts.

The Opioid Guideline Workgroup (OGW) “comprised clinicians, subject matter experts, and a patient representative, with the following perspectives represented: primary care, pain medicine, public health, behavioral health, substance abuse treatment, pharmacy, patients, and research.”

As you can see, the 10 members of the Opioid Guideline Workgroup failed to include one chiropractor:

  • Erin Krebs, MD, MPH, an investigator with the Department of Veterans Affairs' Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota
  • Mitchell H. Katz, MD, director of the Los Angeles County Department of Health Services, California
  • Mark Steven Wallace, MD, chair of the Division of Pain Medicine at the University of California, San Diego Medical Center
  • Gregory Terman, MD, PhD, professor and director of Pain Medicine Research at the University of Washington, Seattle
  • Katherine Galluzzi, DO, professor and chair of the Department of Geriatrics at the Philadelphia College of Osteopathic Medicine, Pennsylvania
  • Christina Porucznik, PhD, MSPH, associate professor of family and preventive medicine at the University of Utah School of Medicine, Salt Lake City
  • Penney Cowan, founder of the American Chronic Pain Association, Rocklin, California
  • Chinazo Cunningham, MD, MS, professor of medicine and family and social medicine at Albert Einstein College of Medicine, Bronx, New York
  • Anne Burns, RPh, vice president, professional affairs at the American Pharmacists Association, Washington, DC
  • Traci Green, PhD, MSc, associate professor, emergency medicine, and associate director of the Injury Prevention Research Center at Boston University Medical Center, Massachusetts

Seemingly this is a comprehensive list of medical specialties. However, once again the “elephant in the room” was evident. Considering the fact that chiropractors constitute the third-largest physician-level health profession in the world that focuses on spine-related disorders and MSDs with nondrug treatments, the exclusion of chiropractors on this panel speaks volumes about the systematic bias of this OGW.

This partisan panel excluded any chiropractic researcher, such as Scott Haldeman, MD, DC, PhD, John J. Triano, DC, PhD, William C. Meeker, DC, MPH, Reed B. Phillips, DC, PhD, Christine Goertz, DC, PhD, Anthony Rosner, PhD, Robert D. Mootz, DC, Associate Medical Director for Chiropractic at the State of Washington Department of Labor & Industries, Claire Johnson, DC, MSEd, PhD or Paul B. Bishop, DC, MD, PhD, to name but a few of notable researchers within the chiropractic profession.

This oversight is equivalent to holding a conference on race relations and omitting the NAACP. Indeed, didn’t it occur to any panelist the chiropractic profession was not represented to contribute to the issue of nondrug care for chronic pain? Apparently chirophobia runs deep among people at the CDC.

As evidence of more bias, the 12 recommendations by the CDC Guideline were also reviewed by representatives from the Society of General Internal Medicine, American Academy of Family Physicians, and American College of Physicians.

Again notably missing was any chiropractic organization such as the American Chiropractic Association, World Federation of Chiropractic or the Council on Chiropractic Guidelines and Practice Parameters.

However, there was a ray of hope with one OGW panel member, Erin E. Krebs, MD, MPH, who spoke at the 32nd Annual American Academy of Pain Management (AAPM) conference in February, 2016, concerning the CDC Guideline. She made a few remarkable comments on the conference theme of “ensuring access to pain care”:

“We also need to put opioids in their place. Opioids are only one treatment for pain and probably not the best treatment for most people with chronic pain. If we can ensure all patients with chronic pain are getting optimal non-opioid pain care, our use of opioids will be more targeted and more effective.”[33] 

Certainly the chiropractic profession can make the case that “optimal non-opioid pain care” for the majority of spine-related and musculoskeletal problems is our brand of nondrug treatments.

Dr. Krebs, both a CDC and VA advisor, also mentioned the lack of access to nondrug treatments:

 “Lack of access to other pain treatments is part of the reason for opioid over-prescribing. We have evidence-based treatments for pain — mostly ‘low-tech, high-touch’ treatments — that most people with chronic pain can't access.”[34] 

In a nutshell, Dr. Krebs described chiropractic’s dilemma – the lack of access for the millions of pain patients who need our nondrug care but who face referral barriers from biased MDs and restrictions in healthcare insurance systems such as the VA, Medicare, workers’ compensation programs, and group health insurances that constrain access to our care.

Filling the Vacuum

In every storm cloud, there is a silver lining. This CDC Guideline on the opioid pandemic ignored chiropractors, but inevitably the truth will come forth as the epidemic of addiction and deaths worsens with the promiscuous prescribers still at the helm and Big Pharma fueling them with even stronger opioids.

Robert Lynch, DC, a member of the Maine Board of Chiropractic Examiners, put this situation bluntly in his testimony to members of the Health and Human Services Committee concerning state legislation to Prevent Opiate Abuse by Strengthening the Controlled Substances Prescription Monitoring Program:

“We need an innovative and disruptive solution to the problem. We cannot expect the medical providers and institutions to solve the problem that they helped create. There is a smoking gun and it is the prescription pad. The training and the ammunition is provided by the pharmaceutical companies. The insurance companies are also to blame for being too liberal with their policies about opioid prescriptions.” [35]

The most obvious “innovative and disruptive solution” is to stop relegating chronic pain patients to untrained and promiscuous prescribing MDs holding the “smoking gun” of prescription pads doling out the “ammunition” of opioid drugs supplied by Big Pharma.

With more powerful and dangerous drugs on the market, the CDC Guideline with voluntary recommendations appears to be simply rearranging the deck chairs on the sinking medical ship Titanic with a crew hell-bent on selling more opioids, not less.

However, some see a change in course.

 “I think the acceptance of alternative therapies needed to have a vacuum to fill,” said Dr. Houman Danesh, director of Integrative Pain Management at Mount Sinai Hospital in New York. “Essentially what the opioids did was create that vacuum.”[36]

Hopefully the chiropractic profession will fill this vacuum; indeed, there is not a better solution to this chronic musculoskeletal pain paradox. This is a golden opportunity to promote our profession as the reasonable nondrug choice as many professional guidelines now suggest.

In fact, the CDC should be calling “all hands on deck”, including chiropractors, to avoid the inevitable opioid torpedoes that will continue to come.

Until the course of this Titanic is changed with “innovative and disruptive” solutions with a new crew on-board, the millions of Americans becoming dependent and addicted to opioid painkillers will not stop. “Full steam ahead” is the attitude of Big Pharma and its complicit crew of prescribers.

It’s time for the CDC to think out of the medical black bag of drugs and set a safer course with a new crew of nondrug CAM providers with chiropractors at the helm. Indeed, this is the most “innovative and disruptive solution” to this onslaught of opioids.

 



[1] Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. REPORT BRIEF JUNE 2011; Johannes et al. The prevalence of chronic pain in United States adults: results of an Internet-based survey. J Pain. 11(11):1230-9. (2010); Gallup-Healthways Well-Being Index.

[2] De Leon Casada. Opioids for Chronic Pain: New Evidence, New Strategies, Safe Prescribing The American Journal of Medicine, 126(3s1):S3–S11. (2013).

[3] Robert Lowes, “CDC Issues Opioid Guidelines for 'Doctor-Driven' Epidemic,” www.medscape.com, March 15, 2016

[4] Paulozzi LJ, Mack KA, Hockenberry JM. Vital signs: variation among states in prescribing of opioid pain relievers and benzodiazepines—United States, 2012. MMWR Morb Mortal Wkly Rep 2014;63:563–8. PubMed

[5] “Purdue Pharma has privately identified about 1,800 doctors who may have recklessly prescribed the painkiller to addicts and dealers, yet it has done little to alert authorities,” by Scott Glover and Lisa Girion, Los Angeles Times, August 11, 2013

[6] C Waismann, FDA Approves OxyContin for Kids: Could Lifelong Addiction Follow?

August 19, 2015

[8] Andrew Kolodny, M.D., “Zohydro: The FDA-Approved Prescription for Addiction,” The Huffington Post, March 6th, 2014

[9] Deyo, RA. Low -back pain., Scientific American, pp. 49-53, August 1998.

[10] EA Joy, S Van Hala, “Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/11 (November 2004).

[11] PB Bishop et al., “The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A Randomized Controlled Trial On The Effectiveness Of Clinical Practice Guidelines In The Medical And Chiropractic Management Of Patients With Acute Mechanical Low Back Pain,” presented at the annual meeting of the International Society for the Study of the Lumbar Spine Hong Kong, 2007; presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; Spine, in press.


[12]
SS Bederman, NN Mahomed, HJ Kreder, et al. In the Eye of the Beholder: Preferences Of Patients, Family Physicians, And Surgeons For Lumbar Spinal Surgery,” Spine 135/1 (2010):108-115.

[13] Jonathan Chen, Overprescribing of opioids is not limited to a few bad apples, Stanford Medicine News Center, Dec 14 2015

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

[15] Da Hee Han, PharmD, “Survey Finds Most Doctors Prescribe Opioids for Longer Than CDC Advises,” MPR Daily Dose, March 28, 2016

[16] 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.

[17] Brinjikji W, et al., Systematic literature review of imaging features of spinal degeneration in asymptomatic populations, American Journal of Neuroradiology, 2014, prepub ahead of print; www.ajnr.org/content/early/2014/11/27/ajnr.A4173.long.

[18] The BACKLetter, Vol. 31, No. 4, April 2016

[19] 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.

[20] John McMillan Mennell, The Musculoskeletal System: Differential Diagnosis from Symptoms and Physical Signs. Aspen Publications, 1992, p. 22.

[22] SJ Bigos, O Bowyer, G Braea, K Brown, R Deyo, S Haldeman, et al. “Acute Low Back Pain Problems in Adults: Clinical Practice Guideline no. 14.” Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; (1992) AHCPR publication no. 95-0642.

[23] Davis MA, Yakusheva O, Gottlieb DJ, Bynum JP. Regional Supply of Chiropractic Care and Visits to Primary Care Physicians for Back and Neck Pain.”J Am Board Fam Med. 2015 Jul-Aug;28(4):481-90. doi: 10.3122/jabfm.2015.04.150005.

[24] Chiropractic Care Study, Senate Report 110-335 accompanying the National Defense Authorization Act for FY 2009; letter sent to Congressmen by Ellen P. Embrey, Deputy Assistant Secretary of Defense (September 22, 2009):2.

[25] “Relief for Aching Backs:  Hands-on Therapies were Top Rated by 14,000 Consumers,” Consumer Report (May 2009)

[26] http://www.palmer.edu/uploadedfiles/pages/alumni/gallop-report-palmer-college.pdf

[27] The Gallup Organization, Democratic Characteristics of Users of Chiropractic Services (Princeton, NJ:  The Gallup Organization (1991)

[28] 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.

[29] SJ Bigos, O Bowyer, G Braea, K Brown, R Deyo, S Haldeman, et al. “Acute Low Back Pain Problems in Adults: Clinical Practice Guideline no. 14.” Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; (1992) AHCPR publication no. 95-0642.

[30]  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

[32] G McAndrews, “Plaintiffs’ Summary of Proofs as an Aid to the Court,” Civil Action No. 76 C 3777, Wilk, (June 25, 1987) Throckmorton, Howard, Taylor, and Monaghon Deps.

[33] “What the CDC's Opioid Prescribing Guidelines Mean for Primary Care Physicians,” Clinical Pain Advisor, February 19, 2016

[34] “What the CDC's Opioid Prescribing Guidelines Mean for Primary Care Physicians,” Clinical Pain Advisor, February 19, 2016

[36] “The opioid abuse epidemic: How healthcare helped create a crisis,” by Steven Ross Johnson, Modern Healthcare, February 13, 2016

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