Articles by JCS

Executive Orders

Executive Orders

 

 

President Obama recently ordered Vice President Biden to head an inquiry into gun control after the devastating incident at Sandy Hook Elementary School, stating he might invoke an executive order to implement recommendations immediately without the approval of Congress.

At a follow-up press conference, Mr. Biden made it clear that all options will be on the table when discussing this important issue of gun control, even over the objections of the NRA that steadfastly opposes any gun control.

In effect, another presidential executive order was recently issued by former President Clinton during the broadcast of Sanjay Gupta’s Deadly Dose exposé on CNN that originally aired on November 18, 2012.

This special program focused on the growing abuse and deaths from prescription narcotic painkillers (Oxycodone, Percocet, OxyContin, Hydrocodone), euphemistically dubbed the Hillbilly Heroin epidemic.

President Clinton urged Dr. Gupta to report on this topic after a friend’s son died from a dose of narcotic painkillers mixed with alcohol—a deadly concoction for thousands annually.

According to Dr. Gupta, “President Clinton said to me, ‘nobody thinks that taking OxyContin and having a few beers is good idea, but you also don't think you're going to die.’”[1]

Vinod Gupta, the victim’s father but no relation to Dr. Gupta, recently made a one million dollar pledge to the Clinton Global Initiative to support the former president's passion about this issue by educating people about the dangers of misusing prescription drugs.

According to President Clinton, “[Mr. Gupta] said, ‘I have been very fortunate and my son was worth $1 million.’”

Clinton’s interview on this documentary was palpable as he called for “a national conversation” to make this problem better known.[2]

President Clinton said, “We—all of us, the whole culture—we need to start thinking about this. This is crazy. Not a single solitary one of these people had to die.”

For all intents and purposes, I take his plea as a de facto executive order to investigate this problem, discuss all options, and make recommendations. Of course, one option is chiropractic care.

As with the debate on gun control, all options should be on the table during this national conversation about solving the epidemic of deaths from painkillers that has quickly become a bigger problem than most people ever realized.

Deaths by Medicine

In fact, more Americans die annually from narcotic painkillers than die from car accidents, gunshot wounds, or all soldiers who died in the Mid-East wars.[3] According to the Centers for Disease Control and Prevention, "These drugs were involved in more deaths than cocaine and heroin combined."[4]

Dr. Gupta mentioned in his program, “In fact, the most recent data shows 37,000 drug overdose deaths in one year, mostly accidental. About 21,000 involved prescription drugs and of those 75 percent were painkillers.”[5]

These deaths, however, cannot be considered purely “accidental” when most patients were prescribed these narcotics by their primary care physicians. “Unintentional” may best describe this problem since patients were deliberately given these dangerous narcotics.

However, some MDs are now having second thoughts about these narcotics, including the godfather of painkillers, Dr. Russell Portenoy, who campaigned for wider use of opiate pain medications.

Previously these opiates were used mainly for long term cancer patients, but due to his strong urging, they are now used for chronic pain patients, which opened up a huge new market for Big Pharma.

Dr. Portenoy admits in a recent interview in The Wall Street Journal, “Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did.”

Dr. Portenoy admits: “We didn't know then what we know now. I gave innumerable lectures in the late 1980s and '90s about addiction that weren't true."[6]

Quite an admission from a doctor who probably made millions from Big Pharma giving lectures encouraging other doctors to use these deadly drugs as we’ve learned after an investigation into medical payola.

He originally argued that opioids were a "gift from nature" that was being forsaken because of "opiophobia" among doctors.

Dr. Portenoy said "We had to destigmatize these drugs."

And that he certainly did to the point that seemingly anyone with any chronic pain is now given narcotics.

As a result, “pain management” clinics are the fastest growing medical offices despite the dangers from epidural shots and opioid drugs.

Dr. Stephen Anderson also confessed during Gupta’s exposé, “We have seen absolute skyrocketing of overdose deaths that correlate directly with the number of prescriptions that are written.”[7]

The proliferation of “pill mills” that dispense narcotics like Halloween candy recently led Thomas Frieden, MD, director for CDC, to admit that physicians have supplanted street corner drug pushers as the most important suppliers of illicit narcotics,[8] a shocking opinion Dr. Gupta omitted in his storyline in order to avoid tarnishing his medical colleagues.

To his credit, Dr. Gupta did allude to the abundance of prescription drugs. “The problem, in part, is that here in the United States, we are being flooded with painkillers. Consider this, Americans take 80 percent of the world's painkillers…that increased by 600 percent between 1997 and 2007.”[9]

According to the FDA, nearly 23 million U.S. prescriptions for extended-release and long-acting opioids were dispensed in 2011, However, research in the past few years have shown that these pain relieving morphine medications can actually make the pain worse.

This paradoxical condition known as hyperalgesia presents a challenge for physicians and pain specialists who treat chronic pain patients solely with painkillers.[10] In other words, taking more drugs for more pain is simply fanning the flame with more fuel.

The Source of the Dilemma: Back Pain

Like many people, Dr. Gupta initially believed the people who overdosed on pain pills were common drug abusers, but he soon found most were suffering from back pain.

“We thought these are guys on the street, maybe using heroine,” said Dr. Bill Hurley who is the medical director of the Poison Control Center and a trauma doctor in Washington State.

Dr. Gupta elaborated: “But looking deeper, Dr. Hurley realized they weren't junkies, not at all. It usually began with a back sprain.”[11]

Low back pain ranks in the top three ailments in terms of total medical costs of any condition in the country, and more than 80 percent of these cases are considered non-surgical cases according to Becker’s Spine Review, an orthopedic surgeon website.[12]

Although not deadly like heart disease or cancer, the back pain pandemic currently costs an estimated $267.2 billion annually and will strike most of the 250 million American adults sometime in their lifetime.[13]

For example, nearly one-third of adults will suffer daily with low back pain, which equates to 92.5 million people; the annual prevalence rate is two-thirds of adults, which equates to 190 million; and the lifetime prevalence of a back attack is 85% or 212.5 million adults.[14]

Professional Amnesia

Dr. Gupta’s admission that back pain was the underlying reason for this drug abuse piqued my interest as a chiropractor. It probably also caught the attention of the twenty million patients who already use chiropractic care and their 80,000 doctors of chiropractic.

Inexplicably, Dr. Gupta failed to mention just once during the entire 60-minute program the “C” word and the benefits of America’s primary non-drug spine care providers, chiropractors.[15]

His omission is precisely the solution he must address in Deadly Dose—that is, finding a non-drug solution to back pain.

Seriously, how can Dr. Gupta speak of solving the abuse of painkillers mainly used for back pain and not mention chiropractic care, which today is the third-largest, physician-level health profession in the country?

As a neurosurgeon and award-winning journalist at CNN, Dr. Gupta knows full well of the positive research guidelines that recommend chiropractic care for the epidemic of back pain, or at least he should be.

Ironically, after decades of being branded as unscientific because chiropractors do not prescribe drugs, this current drug abuse crisis suggests chiropractors should now be applauded for developing non-drug solutions to chronic pain and disease.

But swallowing this medicine will be very bitter for the medical profession after years of waging war on chiropractors.

It must be terribly difficult for MDs to admit their “wonder drugs” are not so wonderful, whether it is antibiotics causing super bug infections like MRSA or painkillers causing addiction and deaths.

Of course, few people are so naïve not to understand the medical bias against chiropractors is the leading cause of Dr. Gupta’s obvious omission.

As a neurosurgeon and award-winning journalist at CNN, he knows full well of the positive research guidelines that recommend chiropractic care for the epidemic of back pain, or at least he should be. His omission is equivalent to speaking about tooth pain and omitting dentistry as a reasonable solution.

Certainly Dr. Gupta is not ignorant, so his sudden journalist forgetfulness can only be explained as his medical bias. [16]

However, most fair-minded medical professionals would admit the obvious—if chiropractic is good for anything, it is for back pain.

Actually, there is already a national discussion on this topic of narcotics. Dr. Gupta’s report is not the first time the issue of opioid addiction and death has been discussed.

In May 2012, at the 31st Annual Scientific Meeting of the American Pain Society, Beth D. Darnall, PhD, now Clinical Associate Professor at Stanford University, moderated a panel discussion on translating opioid research into clinical practice.

Once again I find it odd that this panel failed to include a chiropractor to address chiropractic care as a non-drug solution to chronic pain.

Despite this obvious omission, the panelists were very critical of medical methods and suggested options that again failed to mention the “C” word.

Charles E. Argoff, MD, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Program at Albany Medical Center, spoke of “a frankly immoral pain management system” that does not offer alternatives to drugs, shots, and surgery.

Michael E. Schatman, PhD, Executive Director of the Foundation for Ethics in Pain Care, added,It is not a coincidence that the decrease in the availability of interdisciplinary pain management in the United States has paralleled our dramatic increase in opioid prescription and the tragedies that have accompanied this mode of pain practice.”

Not only have pain clinics ignored non-drug solutions like chiropractic care, acupuncture, or massage therapy (CAM), the insurance industry is just as negligent.

Dr. Schatman explained, “By refusing to pay for interdisciplinary pain management programs while covering chronic opioid therapy, the American insurance industry is, at a minimum, passively encouraging the proliferation of non-evidence-based and potentially deleterious and dangerous chronic opioid therapy.”

Indeed, many patients are literally railroaded into opioids or surgery when their insurance denies or limits CAM care.

Dr. Schatman mentioned that “Open access to all strategies in a truly widely interdisciplinary—not bare minimum—manner would likely result in reduced over-reliance by specific practitioners on one type of treatment over another.”

Jane C. Ballantyne, MD, Professor of Pain Medicine at University of Washington, agreed. “Any attempt to cut back on opioid prescribing tends to be countered with: ‘If we don't give opioids, what else can we give?’”

Perhaps the best answer to this question is not what to “give” patients, but how to address the underlying mechanical problem. She addresses this issue: “The reason interdisciplinary programs work best is that they allow patients and their providers to explore pain's deepest roots, which are not addressed by drugs, injections, or operations.”

Dr. Ballantyne raises another important issue—“prescribers may not know what else to do”.

In fact, this is more of a problem of bias and the lack of proper education because every MD is painfully aware of their chiropractic rivals.

In fact, researchers have revealed that medical primary care physicians are actually the least educated to diagnose and treat musculoskeletal chronic pain problems.[17]

Moreover, patients don’t realize that 50% of all medical schools do not even teach one class in musculoskeletal disorders.[18]

And what is taught by the other half of med schools is outdated concepts and treatments—drugs, shots, and surgery. “And whatever you do, never refer patients to a chiropractor” is the advice of too many biased medical school instructors.

The opinion that most MDs are untrained in musculoskeletal disorders is not a surprise to Dr. Scott Boden, Emory University professor of orthopedic surgery and director of the Emory Orthopaedics & Spine Center. He admitted, “Many, if not most, primary medical care providers have little training in how to manage musculoskeletal disorders.”[19]

Many spine researchers now conclude that medical primary care physicians are typically inept in their training on musculoskeletal disorders,[20] prone to ignore recent guidelines that do not recommended narcotics,[21] and more likely to suggest spine surgery than surgeons themselves.[22]

Another huge problem rests with misdiagnosis and mistreatment in spine care. What matters most, as studies now confirm, is how the spine functions, not the amount of abnormal discs on an MRI image that are actually common in most adults, including those without any back pain.

Many spine researchers have concluded that “many of these abnormalities are trivial, harmless, and irrelevant, so they have been dubbed “incidentalomas,” because they may be incidental to the actual source of pain.[23]

The lack of musculoskeletal education combined with the discounted disc theory and the historical prejudice of MDs toward chiropractors makes for a deadly dose of ignorance and bias that leads to medical mistreatments, addictions, and deaths.

In the closing arguments of the second Wilk trial, George McAndrews also pointed out there was no effort by the AMA to incorporate the skills of chiropractors into the mainstream healthcare to help patients:

This is the evil that is still permeating this country. Every medical physician in this country has been exposed to that from the first day of medical school on.  That’s all we need, is the medical school students being told they are rabid dogs and killers, and not mentioning the fact that the medical students aren’t getting the proper education in the musculoskeletal system.

Dr. Ballantyne also asks the obvious: “Would opioid prescribing be reduced if we had more interdisciplinary pain programs in the United States?”

The answer is an overwhelming “yes.”

In fact, this tsunami of drugs and surgery has led the editor of an international spine research newsletter from Georgetown University to state, “Spinal medicine in the US is a poster child for inefficient spine care.”[24]

This public persecution by the AMA not only caused chiropractors to be stigmatized and marginalized, but the boycott also caused collateral damage to patients by denying them access to chiropractic care that has now been vindicated as one of the leading treatments for the epidemic of back pain.

George McAndrews also commented on the low image cast upon chiropractors by the AMA propaganda:

And what has happened here is that the might of a $60 million a year budget at the AMA was directed against eliminating the second largest health care profession in this country, not helping it, not joining hands, not sitting down and getting together and saying: you have certain skills, there’s no doubt about that.

 

Without a doubt, if this illegal medical war had never occurred and subsequently had allowed the development of a free market place open to fair competition on a level playing field, chiropractors would be known today as America’s primary spine care providers by virtue of their superior training and clinical expertise. Furthermore, neither the current back pain epidemic nor the resulting narcotic drug abuse problems would exist today at the present epidemic levels.

When President Clinton’s national discussion actually materializes, the chiropractic profession must have a seat at the table to offer a non-drug alternative to the addictive and deadly prescription drugs that President Clinton and Dr. Gupta bemoan.

Time for Paradigm Shift in Spine Care

At the end of his exposé on deadly drugs, Dr. Gupta concluded, “In a nation overflowing with so many pills, with so many patients wanting and expecting a quick fix, so many truly naive prescribers, users and misusers of medications, we have to find a way to prevent people from taking a deadly dose.”[25]

Let me suggest to President Clinton, Dr. Gupta, and the American public that the most obvious way to prevent many people from taking a deadly dose of drugs is to utilize chiropractic spine care as the first avenue of treatment for chronic pain as the guidelines already recommend for the majority of back pain cases.

However, that is easier said than done. According to Michael Schatman,  “It is not a coincidence that the decrease in the availability of interdisciplinary pain management in the United States has paralleled our dramatic increase in opioid prescription and the tragedies that have accompanied this mode of pain practice.[26]

The real solution to improving the health of Americans is to give them a freedom of choice to the present medical monopoly where patients are forced into drugs, shots, and surgery while CAM methods are excluded or severely limited by medical bureaucrats in the insurance industry like Medicare, workers’ comp, the VA, and military health services.

Dr. Schatman also admits, “While it is easy to blame physicians for being irresponsible in their prescription of opioid analgesics, the demise of interdisciplinary treatment begs the question of what else the physician can offer the patient with chronic pain.”

Despite the need for non-drug alternatives, the medical world continues to ignore chiropractic care, hoping it “withers on the vine” rather than embracing it wholeheartedly as a safe, effective, and inexpensive way to treat this epidemic of chronic pain and a natural way to avoid a deadly dose.

Another panelist, Charles Argoff, MD, admits the availability of treatments depends upon "what will be paid for" that often becomes a potential severe detriment to the patient.[27]

This problem has been a persistent barrier to every patient who seeks chiropractic care when medically-biased insurance payers often deny or limit access to chiropractors.

 Dr. Schatman remarked about this insurance discrimination:

“By refusing to pay for interdisciplinary pain management programs while covering chronic opioid therapy, the American insurance industry is, at a minimum, passively encouraging the proliferation of non-evidence-based and potentially deleterious and dangerous chronic opioid therapy.”[28]

Conclusion

Just as gun control must be confronted, so must the chronic pain epidemic and drug abuse be addressed with all options on the table. No longer can the NRA shout down people who want gun control of automatic weapons and no longer can the AMA shout down the benefits of chiropractic care as it has in the past.

President Clinton’s executive order and call for action cannot be stymied by medical stubbornness as we’ve seen in the past when it comes to promoting chiropractic care for the epidemic of chronic back pain.

Dr. Argoff asks the obvious question: “How can we have a meaningful discussion about opioid therapy in the United States without an honest recognition of the healthcare system factors that underlie it?”

Unfortunately, there are many factors that need to be discussed, but few want to point fingers at an immoral pain management industry gone wild, untrained medical PCPs, medical bias against chiropractic providers, toxic epidural shots, spine surgeons guided by incidentalomas, a corrupt drug industry profiting by the abuse of patients, and an insurance industry with perverse motivations that discourages cheaper treatments.

The proof is positive and research studies cannot be clearer that chiropractic now stands at the top of spinal treatments as Anthony Rosner, PhD, testified in 2003 before The Institute of Medicine: “Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”[29]

Certainly it is past time for a paradigm shift to more clinically-effective and drugless methods such as chiropractic care. It is time for Dr. Gupta to tell the world of this paradigm shift if his goal is to prevent more deadly doses and if he is to be taken seriously as an objective newsman or just another medical shill.



[1] CNN Presents: Deadly Dose, aired November 18, 2012

[2] CNN Presents: Deadly Dose, aired November 18, 2012

[3]wiki.answers.com/Q/How_many_gunshot_deaths_occur_each_year_in_the_US

[4] Timmermans S, Mauck A. The promises and pitfalls of evidence-based medicine. Health Aff. 2005;24:18-28.

[5] CNN Presents: Deadly Dose, aired November 18, 2012

[6] Thomas Catan and Evan Perez, A Pain-Drug Champion Has Second Thoughts, WSJ, December 17, 2012

[7] CNN Presents: Deadly Dose, aired November 18, 2012

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

[9] CNN Presents: Deadly Dose, aired November 18, 2012

[10] Debbie Nicholson, Chronic pain drug morphine just may make that pain worse, AllVoices, Jan 07, 2013

[11] CNN Presents: Deadly Dose, aired November 18, 2012

[12] Laura Miller, 5 Tips for Spine Surgeons to Collect More From Payor Contracts, January 10, 2013

[13] The Burden of Musculoskeletal Diseases in the United States Bone and Joint Decade, Copyright © 2008 by the American Academy of Orthopaedic Surgeons. ISBN 978-0-89203-533-5, pp. 21.

[14] Scott Haldeman DC, MD, PhD, FRCP(C) and Simon Dagenais DC, PhD. A supermarket approach to the evidence-informed management of chronic low back pain. The Spine Journal, vol. 8, Issue 1, January-February 2008, Pages 1-7.

[15] Donald R Murphy et al.,  “The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States,” Chiropractic & Manual Therapies 2011, 19:17 doi:10.1186/2045-709X-19-17

[16] A Rosner, “Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient,” Dynamic Chiropractic, 20/25 (November 30, 2002)

[17] AD Woolf, B Pfleger, “Burden of Major Musculoskeletal Conditions,” Bull World Health Organ 81/09 (2003):646-656.

[18] Matzkin E, Smith MD, Freccero DC, Richardson AB, Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am 2005, 87-A:310-314

[19] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28(2003):524-525.

[20] Elizabeth A. Joy, MD; Sonja Van Hala, MD, MPH, “Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/ 11 ( November 2004).

[21] 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.

[22] 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.

[23] Richard A. Deyo, MD, MPH and Donald L. Patrick, PhD, MSPH, Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises, AMACOM books, (2005): 36-37

[24] The BACKPage editorial vol. 27, No. 11, November 2012.

[25] CNN Presents: Deadly Dose, aired November 18, 2012

[26] Beth D. Darnall, PhD, Michael E. Schatman, PhD, CPE, Charles E. Argoff, MD, Jane C. Ballantyne, MD, Understanding Opioids: Part 1,www.medscape.com, Jan 09, 2013

[27] Beth D. Darnall, PhD, Michael E. Schatman, PhD, CPE, Charles E. Argoff, MD, Jane C. Ballantyne, MD, Understanding Opioids: Part 1,www.medscape.com, Jan 09, 2013

[28] Beth D. Darnall, PhD, Michael E. Schatman, PhD, CPE, Charles E. Argoff, MD, Jane C. Ballantyne, MD, Understanding Opioids: Part 1,www.medscape.com, Jan 09, 2013

[29] Testimony before The Institute of Medicine: Committee on Use of CAM by the American Public on Feb. 27, 2003.

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