Articles by JCS

Letter to DVA McDonald

                                                                                                                                                       

 

 

                                                                      August 12, 2014

 

TO:              Sec. Robert McDonald

                    Debi Bevins, Director of Client Relations

 

FROM:         JC Smith, MA, DC

RE:              "Veterans Access, Choice, and Accountability Act of 2014”

Executive Summary

When President Obama signed the VA reform bill he mentioned the “Veterans Choice Card” will take effect within 90 days. Before the policy is set, I would like to offer a solution to the ‘Hillbilly Heroin’ turmoil in the DVA that recently broke in the media about prescription painkiller drug abuse among veterans suffering from chronic pain.

Despite calls for more choice within the DVA, the “Choice Card” will be a false-choice if veterans are not given equal access to non-drug care by Doctors of Chiropractic (DCs) for the well-documented epidemic of chronic low back pain (CLBP), the #1 disability among veterans.

Evidence-based comparative studies on CLBP have already found chiropractic care is faster, safer, cheaper, and longer-lasting than current medical spine care treatments consisting of narcotic painkillers, epidural steroid injections, and spine fusion surgery. Numerous patient satisfaction surveys also support chiropractors as the preferred choice for CLBP.

That being said, presently veterans are restricted access to chiropractic services and, inexplicably, veterans are required to take narcotics and steroids before they are allowed to seek chiropractic care. This ‘pill mill’ practice flies in the face of “best practice” guidelines that clearly call for non-drug, non-invasive spine care first. This incongruent policy has greatly contributed to the bad publicity about the DVA evident by the numerous articles in the media about opioid addiction among veterans.

If this new VA reform legislation is successful to reduce the narcotic painkiller abuse, veterans must be given undeterred access and a real choice in regards to non-drug chiropractic care for CLBP. This transformation begins by holding the DVA accountable to fully utilize DCs who are now regarded as America’s primary spine care providers.[1]

 

 

Table of Contents

“Seize the Opportunity”   

Choice Card or False-Choice?

Back Pain: Bigger than Bullets

Positive Findings in Back Pain Studies

Say No to Drugs

“Don’t Ask, Won’t Tell

Patients Abused by Doctors

 “Prejudices & Controversy” in Medical Spine Care

Say Yes to Chiropractic

 

“Seize the Opportunity

Upon signing the VA reform bill President Obama admitted, “Over the last few months, we've discovered some inexcusable conduct. It was wrong, outrageous.”

As a 35-year chiropractic practitioner and back pain specialist working in Warner Robins near both Robins AFB and the Dublin VA hospital, I concur with the president as well as Senator Saxby Chambliss (R-GA) who recently opined that the VA reform bill will “fix the longstanding dysfunction within the VA healthcare system… The fact that our veterans have been systematically mistreated and inadequately cared for is simply unacceptable.”[2]

Today a case can be made that traditional medical spine care has “systematically mistreated and inadequately cared for” both Active Duty Service Members (ADSM) and veterans evident by the fact that chronic low back pain (CLBP) is now #1 disabling condition, including all traumatic injuries. [3]

Acting Secretary Sloan Gibson was correct when he told the Senate Veterans Affairs Committee that “We must, all of us, seize this opportunity. We can turn these challenges into the greatest opportunity for improvement in the history of this department.”[4]

Your administration can “seize this opportunity” over the next 90 days for constructive dialogue between various health providers to create a policy for the “Veterans Choice Card” to access chiropractic care that will cut down on the long waiting periods as well as to improve care by providing a real choice to veterans other than more drugs, shots, and surgery for their spine care.

Hopefully this challenge will have a silver lining in the “longstanding dysfunction” within the DVA healthcare system in regards to CLBP with a deeper understanding of the current ineffective practices versus evidence-based non-drug treatments for CLBP to better serve our veterans.

Choice Card or False-Choice?

The Choice Card concept is a step in the right direction, but it does not go far enough. Whether the doctor in the DVA system is on-site or off-site, a false-choice dilemma remains for the patient if there is no real difference among the type of doctors or treatments.

Improving access to more doctors is commendable but merely having a larger selection among identical doctors will not yield a greater choice in treatment. Simply adding more MDs, DOs, or PTs with the same approach will be equivalent to a statement attributed to Albert Einstein: “Insanity is doing the same thing over and over again and expecting different results.”

Chiropractic care has already been shown by the growing number of international comparative studies to be faster, safer, and cheaper than medical spine care for mechanical back pain.[5],[6] Most of all, chiropractic care is drug-free.

Without direct access to Doctors of Chiropractic (DCs), the Choice Card is merely a false-choice between the same medical treatments for CLBP that have proven ineffective and now have led to bad PR about the prescription drug abuse in the DVA.

Actually, the use of chiropractors in the DVA and DoD is not a new issue. In recognition of the value of the services delivered by doctors of chiropractic, in 2000 Congress enacted into law (Public Law 106-398) a permanent chiropractic benefit within TRICARE for ADSM. Similarly, (Public Law 107-135) was enacted in 2001 and provided for the availability of chiropractic care within the DVA health system.

Instead of full implementation and easier access to real choices, only approximately 25% of military treatment facilities (MTF) include DCs because many prejudices and hurdles persist for our veterans and ADSM seeking chiropractic care. 

Back Pain: Bigger than Bullets

The recent flurry of media reports revealed the so-called ‘Hillbilly Heroin’ problem regarding the ‘pill mill’ mentality in the VA where opioid prescription painkillers are indiscriminately dispensed like Halloween candy to veterans.

 “They'd just shove you a bag of pills,” said one veteran addicted to painkillers on NPR’s All Things Considered.  “No matter what you needed, there was a pill. Everything under the sun, from Adderall to Percocet to hydrocodone, oxycodone, you name it."[7]

Recently a  two-part report aired on NPR’s All Things Considered, A Growing Number Of Veterans Struggles To Quit Powerful Painkillers on July 10, 2014 and the second part, Veterans Kick The Prescription Pill Habit Against Doctors' Orders, on July 11. 

On June 30th, the LA Times reported, Pain, Opioid Use Surprisingly High In Soldiers Returning From War, that mirrors a previous Johns Hopkins news release, Back Pain Permanently Sidelines Soldiers At War: Few Rejoin Units In Iraq Or Afghanistan Regardless Of Treatment.

Researchers examined the records of more than 34,000 military personnel evacuated from Iraq and Afghanistan between January 2004 and December 2007. They found that 24% had musculoskeletal disorders, mainly CLBP, compared to 14% who had suffered combat injuries.

According to previous research in 2000 by Johns Hopkins School of Public Health, Unintentional and Musculoskeletal Injuries Greatest Threat to Military Personnel, “...in all three branches of the service, injuries and musculoskeletal conditions resulted in more soldiers missing time from work than any other health condition.”[8]

This study found that 20% of disabled veterans and 30% of hospitalizations stem from CLBP that remains the largest disabling condition among active forces resulting in more soldiers missing time from work than any other health condition.[9]

The Johns Hopkins report was particularly alarming that the ADSM were “systematically mistreated.” According to pain management specialist Army Col. Steven P. Cohen, MD, his research found that among military personnel evacuated out of Iraq and Afghanistan with back pain as their primary diagnosis, only 13% of service members eventually returned to duty in the field.

“If you have only a 13% success rate, this is a failure,” said Dr. Cohen. “There’s a systemic problem.”[10]

In a recent commentary in JAMA Internal Medicine, Pain and Opioids in the Military: We Must Do Better, Dr. Wayne Jonas, an expert on chronic pain, and Dr. Eric Schoomaker, a former surgeon general of the Army, said that “without improvements in pain management, many service members are at risk of increasing disability throughout their lives. The loss of human potential is inestimable…we must transform ourselves in the way we manage pain. We can and must do better.”[11]

Positive Findings in Back Pain Studies

The most obvious way to better manage pain without drugs is to have unrestricted access to chiropractors. The fact is when given a true choice between medical or chiropractic treatments, surveys show that military patients actually prefer chiropractic care over medical care for CLBP and spine-related disorders.

In 2009, the DoD Chiropractic Care Study revealed MTF personnel consider chiropractic care as a “valuable adjunct” to the care offered in the MTFs. The study concluded:

“Chiropractors returned ADSMs to duty faster, and they would select a chiropractor as much or more than a Doctor of Osteopathy or physical therapist.” [12]

Surveys found enormously high patient satisfaction rates where chiropractic care was selectively introduced into the military health services at a few TRICARE facilities:

  • 94% in the Army;
  • Air Force tally was also high with twelve of 19 bases scoring 100%;
  • Navy also reported ratings at 90% or higher; and
  • TRICARE outpatient satisfaction surveys (TROSS) rated chiropractors at 88%, which was 10% “higher than the overall satisfaction with all providers” that scored at 78% percent.[13]

The DoD Chiropractic Health Care Demonstration Program (CHCDP) Minority Report estimated that the inclusion of chiropractic care in the TRICARE would result in significant net savings of $25.8 million annually in “improved outcomes” and would also save 199,000 labor days. Similar savings can be translated to the DVA.[14]

A recent 2013 study published in the medical journal Spine by Christine Goertz, DC, PhD, found 73% of patients who received standard medical care and chiropractic care rated their improvement as pain "completely gone," "much better" or "moderately better." In comparison, 17% of participants who received only standard medical care comparably rated their improvement as high.[15]

Say No to Drugs

One example of the “loss of human potential” is US Army Brigadier General (Ret) Becky Halstead who lost her battle with chronic pain while on active duty. In 2004 she was diagnosed with fibromyalgia and eventually prescribed fifteen medications that left her impaired and “so awful and dysfunctional” that she prematurely retired at the age of 49.

After retiring, she sought chiropractic care and presently takes no medications for pain and her mental clarity has returned as well as her energy. She now urges the “integrative approach” to include chiropractic and alternative methods to avoid the use of drugs and the debilitating side effects she experienced.

General Halstead’s experience is not unusual. According to reports, the VA this year will treat about 650,000 veterans with opiates. One in 3 veterans polled say they are on 10 or more different medications.[16] Abuse of prescription drugs is also high among ADSM who are prescribed narcotic painkillers three times more often than civilians.[17]

“Don’t Ask, Won’t Tell”

The over-use of painkillers is also a factor in the high rate of veteran suicide according to the NPR program. Dr. Gavin West who heads the Opioid Safety Initiative at the VA admitted, "It's a national problem," and he said that the VA is trying to change its approach and stop offering opiates as a first option for pain.[18]

“It's always easier to just prescribe a pill. At the VA, we've really tried to work with other resources. These include acupuncture. We have aqua therapy—you know, pool therapy, and physical therapy. There really is a large arsenal for treating patients' pain.”

Illustrating the systemic bias within the DVA and notably missing from Dr. West’s “large arsenal” is any mention of chiropractic care. This prejudice is historical and well-documented[19], and needs to be held accountable to the new spirit of the "Veterans Access, Choice, and Accountability Act of 2014.”

Similar to racism, sexism, and homophobia in the military, medical bias against chiropractors is well entrenched and there seems to be little incentive for medical gatekeepers within the VA to give veterans a real choice to access DCs even when the good results speak for themselves.

Unfortunately like General Halstead, our veterans go from fighting in real wars to becoming co-lateral damage in the medical turf war against chiropractors. Instead of embracing the non-drug benefits chiropractors bring to the table, the medical gatekeepers appear to have the policy of “Don’t Ask, Won’t Tell” about chiropractic care. 

Where DCs are not on a VA staff, veterans are often discouraged or lied to about chiropractic care. Many experience lengthy delays to off-site chiropractors who are then burdened with unrealistic cookbook limitations; moreover, patients are not allowed any follow-up care to maintain improvement unless it consists of more drugs.

As a practitioner near the Dublin VA hospital, I often hear the tales of woe from mistreated vets. Recently two cases in particular highlight this problem. A former Marine who was hurt during the invasion of Iwo Jima was told he might never walk again with his severely injured low back. After struggling over 60 years with his total disability, he finally limped into my office with the help of his cane. Within a few weeks, his pain has reduced although his disability is permanent.

Then he asked the proverbial question: “Why didn’t they send me to a chiropractor back then?”

Another example is a veteran of the Vietnam War who sought care in my office me after suffering with chronic neck pain and migraine headaches for over forty years. Within a few weeks of chiropractic care his migraines were gone and his neck pain was much improved, yet the VA will not approve more chiropractic treatments although the VA still mails him 120 tablets of Oxycontin each month that he refuses to take.

These are not isolated examples of the “Don’t Ask, Won’t Tell” policy and I am certain if an investigation were undertaken, similar stories would emerge across the nation to substantiate my examples. It is painfully ironic and indicative of the false-choice that the VA medical corps has no problem plying vets with narcotics and steroids while deterring full access to more effective, cheaper, and drugless chiropractic care.

Patients Abused by Doctors

In the recent NPR segment, Dr. Richard Friedman, director of the Psychopharmacology Clinic at Weill Cornell Medical College, spoke of this prescription painkiller abuse. “It's like giving a football player painkillers so he can finish the game, says Dr. Friedman. “It gets him back on the field, but might hurt him worse in the long term.” [20]

However, this drug abuse does not begin as a voluntary choice by our veterans, but the abuse starts with VA doctors who force patients to take narcotic painkillers and epidural steroid injections before they will be referred to chiropractors.

Ironically, if our veterans and ADSM were in the NFL, Olympics, or college football, they would be banned for using the same narcotics and steroids.

This is the false-choice that contradicts the evidence-based guidelines on CLBP that call for conservative, non-drug care before opioid drugs, epidural shots, or spine surgery.

Our veterans should not be forced to take narcotic painkillers and steroid shots before seeking a non-drug solution for back pain. Just as these drugs are banned in sports, they should also be banned in the DVA except for terminally ill cancer patients or acute patients with severe intractable pain as they were originally designed for.

“Prejudices & Controversy” in Medical Spine Care

Without question the evidence for CLBP falls clearly on the side of chiropractic care, but patients still face hurdles to jump. Until the “systemic problem” of medical bias against chiropractors is fixed, patients will continue to suffer with long waiting periods, mistreatment, drug abuse, and disabling CLBP.

Research shows DCs are best prepared to manage this pandemic of CLBP. Not only is chiropractic care a “proven treatment” for back pain according to the US Public Health Service,[21] research has shown that chiropractors are better trained in spine-related and musculoskeletal disorders (MSDs) compared to MDs, DOs, and PTs.

Patients with CLBP are “inadequately cared for” because medical primary care physicians lack training in MSDs,[22] are more prone to ignore recent guidelines,[23] more likely to suggest spine surgery than surgeons themselves,[24] and only 2% of medical PCPs refer to DCs despite their superior training and results.[25]

Indeed, the inadequate medical training for spine-related disorders is shocking according to medical experts themselves. Dr. Scott Boden, director of the Emory Orthopedics & Spine Center, admits, “Many, if not most, primary medical care providers have little training in how to manage musculoskeletal disorders.”[26]

Dr. Boden’s admission followed another startling testimony by John C. Wilson, Jr., MD, former chairman of the American Medical Association’s Section on Orthopedic Surgery:

“The teaching in our medical schools of the etiology, natural history, and treatment of low back pain is inconsistent and less than minimal… At the postgraduate level, symposia and courses concerning the cause and treatment of low back and sciatic pain are often ineffective because of prejudices and controversyMDs often displayed a disturbing ignorance of the cause and treatment of low back and sciatic pain, one of mankind’s most common afflictions.”[27]

Undoubtedly the largest controversy in spine care is the timely death of the “Dynasty of the Disc” that has been the basis of spine fusion since 1934.[28] Support began to erode when Dr. Scott Boden’s seminal MRI study in 1990 confirmed the presence of disc abnormalities in pain-free people.[29]

This began the paradigm shift in spine care away from the medical model to the conservative chiropractic model. Researchers now suggest 50-69% of low back and neck pain is pathophysiology—principally joint dysfunction[30],[31]—that trumps over pathoanatomical issues like ‘bad discs’, adroitly described by Donald Murphy, DC, as “red herrings” to scare patients into surgery.[32]

Researcher Rick Deyo, MD, MPH, chided ‘bad discs’ as irrelevant as “finding grey hair” and dubbed them “incidentalomas” because they are found in pain-free people.[33] Yet thousands of CLBP patients are forced into spine fusion based on an outdated and disproved ‘bad disc’ diagnosis.

Considering there are over 300 joints in the entire spinal column connecting 24 vertebrae sitting atop three pelvic bones while balancing the skull, the likelihood of joint dysfunction as a source of back pain should not come as a surprise or why spinal manipulative therapy (SMT) is now considered the leading treatment in the majority of CLBP cases. [34]

The Agency for Health Care Policy & Research in its 1994 Patient Guideline #14 on acute low back pain in adults confirmed SMT as a “proven treatment” and also revealed the ugly truth about spine surgery:

“Even having a lot of back pain does not by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.”

Moreover, surgery increases the chance of future procedures with higher complication rates…There appears to be no good evidence from controlled trails that spinal fusion alone is effective for treatment of any type of acute low back problems in the absence of spinal fracture or dislocations…Moreover, there is no good evidence that patients who undergo fusion will return to their prior functional level.”[35]

CBS News on April 24, 2014, aired Tapping Into Controversial Back Surgeries concerning the numerous unnecessary spine fusions done annually.

Another controversy concerns pain management clinicians who use epidural corticosteroids injections (ESIs) that have been shown to be no better than placebo.[36] Moreover, ESIs have never been approved by the FDA for back pain as noted in a recent FDA publication, Epidural Corticosteroid Injection: Drug Safety Communication: Risk of Rare But Serious Neurologic Problems.[37]

CBS This Morning also aired on July 3, 2014, a segment on this controversial off-label use of ESI, Aching Backs: New Research Questions Routine Steroid Injections.  

 The ineffectiveness of medical spine care diagnosis and treatments has now burst onto the national scene with a flurry of articles after an investigation in the JAMA Internal Medicine highlighted the Worsening Trends in the Management and Treatment of Back Pain.[38] The authors of this study admit, “Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines.”

The growing evidence in the media reveals the paradigm shift in spine care and supports why Mark Schoene, associate editor of THEBACKLETTER, a leading international spine research journal, declared that “medical spine care is the poster child of inefficient spine care.”  Mr. Schoene also states that “such an important area of medicine has fallen to this level of dysfunction should be a national scandal.”[39]

Indeed, his warning of “a national scandal” has also come true for the DVA. Certainly these “prejudices and controversies” as well as the “Don’t Ask, Won’t Tell” policy in the DVA illustrate how veterans with CLBP are “systematically mistreated and inadequately cared for” with controversial and ineffective medical spine care methods.  

Say Yes to Chiropractic

Research cannot be clearer that chiropractic stands at the top of cost-effective 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.”[40]

Despite the good clinical results, high patient satisfaction surveys, and supportive research, the military health services have not fully implemented chiropractors on all military sites and at all VA hospitals as called for by federal law. Nor do they encourage patients to seek chiropractic care off-site.

Hopefully the new VA reform bill will correct this oversight. If veterans are to have a real choice in regards to treatments for CLBP, the DVA must hold MDs accountable to cooperate with DCs who are now regarded as America’s primary spine care providers.[41]

Indeed, what good is a Choice Card if there is no real choice of treatments for patients? If the DVA is to win the war on drugs by reducing the Hillbilly Heroin epidemic, the DVA should implement undeterred access to chiropractic care at every DVA hospital and/or refer to field chiropractors when necessary without the hurdles and limitations we now see in practice.

In the spirit of the VA reform and the "Veterans Access, Choice, and Accountability Act of 2014,” it is past time for the VA medical corps to end its turf war against chiropractors and join forces to fight together the pandemic of chronic pain among our ailing veterans.

If we are to give hope to injured veterans, it’s time to have an integrated approach but this will require a cultural transformation within the DVA to end the medical bias as well as promote alternative treatments.

Sec. McDonald, the next 90 days is the window to “seize the opportunity” to help our veterans with one of the most debilitating conditions many face that, undoubtedly, will become the silver lining in this crisis.

Simply stated, it is time for the DVA to “Say No to Drugs” and to “Say Yes to Chiropractors” who offer a non-drug and “proven treatment” for back pain.[42]

CC:    BG (Ret) Becky Halstead

Senator Saxby Chambliss

American Chiropractic Association

Foundation for Chiropractic Progress

Association of Chiropractic Colleges

 

References:



[1] DR Murphy, Clinical Reasoning in Spine Pain volume 1, Primary Management of Low Back Disorders Using the CRISP Protocols © Donald Murphy 2013

[2] August 1, 2014 email to his constituents.

[3] Back Pain Permanently Sidelines Soldiers At War, Johns Hopkins New release, Nov. 2009.

[4] VA chief: Fixes would take two years and $17 billion, by Jacqueline Klimas, The Washington Times, July 16, 2014

[5] P Manga, D Angus, C Papadopoulos, W Swan, “The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain,” (funded by the Ontario Ministry of Health) (August, 1993):104

[6] David Chapman-Smith, Cost-Effectiveness Revisited, The Chiropractic Report, November 2009 Vol. 23 No. 6

1 Choudhry N, Milstein A (2009) Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans? An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending. Harvard Medical School, Boston, Mercer Health and Benefits, San Francisco.

3 (2004) United Kingdom Back Pain Exercise and Manipulation (UK BEAM) Randomised Trial: Cost Effectiveness of Physical Treatments for Back Pain in Primary Care, BMJ;329:1381.

4 Manga P, Angus D (1998) Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Outcomes and Achieving Equitable Access to Select Health Services, Ontario Chiropractic Association, Toronto.

5 Stano M, Smith M (1996) Chiropractic and Medical Costs for Low-Back Care, Med Care 34:191-204.

6 Smith M, Stano M (1997) Cost and Recurrences of Chiropractic and Medical Episodes of Low-Back Care, J Manipulative Physiol Ther, 20:5-12.

7 Jarvis KB, Phillips RB et al. (1991) Cost per Case Comparison of Back Injury of Chiropractic versus Medical Management for Conditions with Identical Diagnosis Codes, J Occup Med, 33:847-52.

8 Ebrall PS (1992) Mechanical Low-Back Pain: A Comparison of Medical and Chiropractic Management within the Victorian Workcare Scheme, Chiro J. Aust 22:47-53.

9 Johnson W, Baldwin M (1996) Why is the Treatment of Work-Related Injuries so Costly? New Evidence from California, Inquiry 33:56-65.

10 Jay TC , Jones SL et al. (1998) A Chiropractic Service Arrangement for Musculoskeletal Complaints in Industry: A Pilot Study, Occup Med 48:389-95.

11 Mosley CD, Cohen IG et al (1996) Cost-Effectiveness of Chiropractic Care in a Managed Care Setting, Am J Managed Care 11:280-2.

12 Legorreta AP, Metz RD, Nelson CF et al. (2004) Comparative Analysis of Individuals with and without Chiropractic Coverage, Patient Characteristics, Utilization and Costs, Arch Intern Med 164:1985-1992.

13 Meade TW, Dyer S et al. (1990) Low-Back Pain of Mechanical Origin: Randomised Comparison of Chiropractic and Hospital Outpatient Treatment, Br Med J 300:1431-37.

14 Haldeman S, Carroll L et al. (2008) The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders; Executive Summary, Spine 33 (4S):S5-S7

15 Wolsko PM, Eisenberg DM et al. (2003) Patterns and Perceptions of Care for Treatment of Back and Neck Pain. Results of a National Survey, Spine 28(3):292-298.

16. Whedon JM, Song Y, Davis MA. Spine J., Trends in the use and cost of chiropractic spinal manipulation under Medicare Part B., 2013 Jun 14. pii: S1529-9430(13)00521-4. doi: 10.1016/j.spine.2013.05.012.

 

[7] A Growing Number Of Veterans Struggles To Quit Powerful Painkillers by Quil Lawrence, All Things Considered,  NPR, July 10, 2014

[8] Inteli-Health (Johns Hopkins); March 15, 2000.

[9] Inteli-Health (Johns Hopkins); March 15, 2000.

[10] Back Pain Permanently Sidelines Soldiers At War, Johns Hopkins New release, Nov. 2009.

[11] Invited Commentary: Pain and Opioids in the Military, We Must Do Better by Wayne B. Jonas, MD, LTC (Ret); Eric B. Schoomaker, MD, PhD, LTG (Ret), June 30, 2014

[12] 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): p. 3.

[13] 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.

[14] Report to Congress on Chiropractic in the Military: "Feasible, but not Advisable", Dynamic Chiropractic – April 17, 2000, Vol. 18, Issue 09

[16] Veterans Kick The Prescription Pill Habit, Against Doctors' Orders, by Quil Lawrence, All Things Considered,  NPR, July 11, 2014

[17] Ibid.

[18] Quil Lawrence, ibid.

[20] Quil Lawrence, ibid.

[21] Bigos et al. US Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guideline, Number 14: Acute Low Back Problems in Adults AHCPR Publication No. 95-0642, (December 1994)

[22] 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).

[23] 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

[24] 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.

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

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

[27] JC Wilson,  “Low Back Pain and Sciatica: A Plea for Better Care of the Patient, Chairman's Address,” JAMA, 200/8, (May 22, 1967):705-712.

[28] WJ Mixter and JS Barr, “Rupture of the Intervertebral Disc With Involvement Of The Spinal Cord,” New England Journal of  Medicine 211 (1934):210-214.

[29] SD Boden, DO Davis, TS Dina, NJ Patronas, SW Wiesel, “Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects: A Prospective Investigation,” J Bone Joint Surg Am. 72 (1990):403–408.

[30] Donald R Murphy and Eric L Hurwitz, Application of a diagnosis-based clinical decision guide in patients with neck pain, Chiropractic & Manual Therapies 2011, 19:19

[31] Donald R Murphy and Eric L Hurwitz, “Application of a diagnosis-based clinical decision guide in patients with low back pain,” Chiropractic & Manual Therapies 2011, 19:26

[32] DR Murphy, Clinical Reasoning in Spine Pain volume 1, Primary Management of Low Back Disorders Using the CRISP Protocols © Donald Murphy 2013, p. viii

[33] Deyo RA. Conservative therapy for low back pain: distinguishing useful from useless therapy. Journal of the American Medical Association, 1983;250:1057-62.

[34] G Cramer,  Dean of Research, National University of Health Sciences, via personal communication with JC Smith (April 29, 2009)

[35] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[36] Bicket MC et al, Epidural injections for spinal pain:  A systematic review and meta-analysis evaluating the “control’ injections in randomized control trials, Anesthesiology, 2013; 119:907-31.

[37] Epidural Corticosteroid Injection: Drug Safety Communication - Risk of Rare But Serious Neurologic

Problems,” FDA, April 23, 2014

[38] John N. Mafi, MD; Ellen P. McCarthy, PhD, MPH; Roger B. Davis, ScD; Bruce E. Landon, MD, MBA, MSc, Worsening Trends in the Management and Treatment of Back Pain, JAMA Internal Medicine, September 23, 2013, Vol 173, No. 17

[39] US Spine Care System in a State of Continuing Decline?, The BACKLetter, vol. 28, #10, 2012, pp.1

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

[41] DR Murphy, Clinical Reasoning in Spine Pain volume 1, Primary Management of Low Back Disorders Using the CRISP Protocols © Donald Murphy 2013

[42] Bigos, ibid.


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