Articles by JCS

Picking Our Battles

                                                                                                                                               
the real battle now is to be won in the media, not in the drugstore

Picking Our Battles

There is a potential civil war among DCs raging in Wisconsin that is misguided and misleading. This battle is not about the historical philosophical debate, straight vs. mixer, or technique squabbling, but it involves the resurgent battle over prescription rights.

Similar to the battle in New Mexico (New Mexico Practice Bill Hits Senate Wall, Dynamic Chiropractic, 2011), the Wisconsin Chiropractic Association’s Board of Directors has proposed a Primary Spine Care Initiative that outwardly seems non-controversial until one reads the fine print.

The proposal for a Primary Spine Care Provider program sounds good, one that I’ve promoted in my article, Ladder of Opportunity to position our profession as the primary spine care providers in Medicare by virtue of our superior training and proven treatments. I also promoted this idea in the recent VA Reform effort in a letter to new DVA Secretary Robert McDonald.

As well, I endorsed Dr. Donald Murphy’s course and textbook, “Primary Management of Low Back Disorders Using the CRISP Protocols” as a big step in that direction to prepare DCs to fill this complex role with advanced diagnostics and evidence-based treatments that the general DC fails to learn in college or uses in practice. Certainly we all can agree not every DC is prepared to be a primary spine care provider, nor do many even seek that role.

Without question few DCs are fully positioned to fill this much needed role that is sorely needed in this era when back pain is the #1 disabling condition in the nation, the military, and in the world, which is reason enough why I was delighted to read the WCA proposal (not to be confused with Terry Wrongberg’s defunct World Chiropractic Alliance of Evil Vendors):

WCA Board President Rod Lefler writes:

“There is a battle raging in healthcare…Those who attained better weapons had the upper hand, shaped the outcome in each conflict and changed history.

“Likewise, in healthcare, those who develop the best strategies, implement new tools and advance their education will position themselves to overcome the opposition and secure their future…By becoming primary spine care physicians, chiropractors can position the profession for the 21st Century.

“With the exception of chiropractic, every other health care profession is advancing its training and setting the stage for winning the battle.”

I agree so far with every word Dr. Lefler states. We DCs already have the “best weapons” to treat the pandemic of back pain and spine-related disorders. Now we need to publicly claim our position as America’s PSPs since the medical spine care industry has left our country in clinical shambles at great expense.

Of course, the devil is in the details, and I was shocked to find the call for inclusion of prescription rights, presumably narcotic painkillers, in the WCA White Paper: Filling the Shortage of Primary Care Health Care Providers in Wisconsin: The Primary Spine Care Physician, a new class of health care provider:

“To be more effective at managing care, reduce the burden on primary care and decrease referrals to specialists, Wisconsin should expand the scope of practice for chiropractors trained as PSCPs to include limited prescription rights and the ability to perform some minor procedures.”

Methinks Dr. Lefler is describing the training of an osteopath since medications are definitely not a weapon we need to use in the fight against the pandemic of back pain, mainly because new studies have found OTC and prescription painkillers to be placebo, dangerous, and expensive.

Moreover, nor do drugs correct the underlying pathophysiology of back pain as chiropractic care can do. Two studies by Murphy and Hurwitz found joint dysfunction was the cause of neck pain in 69% of cases and the cause of low back pain (lumbar and sacroiliac) in 50% of patients.[1],[2]

Although back pain can have various causes, such as disc derangement, radiculopathy, and muscle trigger points that are helped by various techniques, the primordial problem in the majority of these cases is joint dysfunction and spinal manipulative therapy (SMT) remains the primary treatment to correct this pandemic of chronic pain.

Push Back on Drugs

Undoubtedly the topic of prescription rights for DCs will push a lot of hot buttons among MDs, DOs, and DCs alike. In a three-part series in Dynamic Chiropractic in 2013, Tom Klapp, DC, ICA and COCSA bigwig wrote The Case Against Drugs in Chiropractic (Part 1): Refuting the arguments for drugs in our profession. (8/15/2013), where he ably argued against such inclusion, so I won’t reiterate his many points but I will add an important issue that has come to bear recently.

I can understand the need to reduce redundant services, but this WCA proposal belies the fact that OTC and prescriptions painkillers have only enriched Big Pharma and created the massive Hillbilly Heroin epidemic.

Do we really want to throw our hat into this den of pill mills? Apparently dispensing opioids is a new version of the Money Hum considering pill mill MDs typically charge walk-in patients $200 for the first visit and $150 a visit thereafter. No diagnostics, no exams, no therapy of any kind, just selling scripts to poor souls addicted to opioids. Easy money if you can sleep at night.

Even the FDA recently warned of this Hillbilly Heroin epidemic in its article,    Opioid Painkiller Prescribing.[3] I urge you to print out the CDC pdf of this article to share with your staff and post to your patients.

According to the FDA report, MDs wrote 259 million prescriptions for opioids in 2012, enough for every American adult to have a bottle of pills according to the FDA. Each day, 46 people die from an overdose of prescription painkillers in the US, killing more people annually than all the car wrecks combined.

Even Dr. Thomas Frieden, Director of the CDC, admitted how low his fellow MDs have stooped when he said, “physicians have supplanted street corner drug pushers as the most important suppliers of illicit narcotics.”

Rolling Over DD

With this plethora of recent data highly critical of narcotic painkillers, it is incredulous to read on the WCA website Dr. Eugene Yellen-Shiring’s article, What Would D.D. Do?, in which he attempts to evoke the blessings of DD for meds:

“Not for the first time in its history, the chiropractic profession is at a crossroads. One hundred and nineteen years after D.D.’s first adjustment, as we consider possible reforms and which direction to take the profession, it is instructive to look back at its origins and the struggles that shaped it. No reform proposal elicits more controversy and divisiveness than the suggestion that some doctors of chiropractic be permitted to incorporate the limited prescription of medication into their practices. Of course we can never know for sure how D.D. Palmer would approach this question. Still, it is both reasonable and useful to perform the thought experiment, using his early writings and studying the evolution of his thinking, and attempt to answer these questions: Are medications compatible with the profession’s principles?

“In conclusion, there is a strong, rational argument that reform which permits the judicious, appropriate use of medication in chiropractic is a reasonable proposal. Should the profession choose to move in such a direction, it can do so in good conscience.”

“…in good conscience”? I daresay DD must be rolling over in his grave to hear a Palmer grad suggesting the use of medications.

I don’t understand how he speaks of the “judicious, appropriate use of medication in chiropractic” since the only cases where opioids are judicious is with intractable pain in cancer victims or acute cases of severely injured patients, those ‘red flags’ that are far outside our scope as spine care providers.

Indeed, it appears this band of misguided brothers are attempting to redefine chiropractic. For example, the ACA Master Plan states, "Chiropractic is a drug-free, nonsurgical science and, as such, does not include pharmaceuticals or incisive surgery." The Association of Chiropractic Colleges (ACC), a group consisting of all the CCE-accredited chiropractic college presidents, defines chiropractic as "a health care discipline that emphasizes the inherent recuperative power of the body to heal itself without the use of drugs or surgery."

Indeed, with the recent flurry of bad news about opioid painkillers from the FDA report, HHS, in the mainstream  media, and even reported on The Daily Show in a segment, “The Pharmaceutical Drug Epidemic” on 9/16/14, it is obvious that to include narcotics into our regimen is nonsense because all medications, OTC or prescription opioids, have been shown to be ineffective, dangerous, and addictive.

As leading-edge spine providers, now is the time we should be advocating a drugless approach since opioids are finally getting much-deserved bad press that has only taken twenty years to get media attention.

We need to jump on this bandwagon to get Americans’ attention that the medical spine care is out of control taking patients on a wild ride on the  medical railroad to drugs, shots, and surgery—the “national scandal” aptly described by Mark Schoene, the editor of a leading international spine journal, who also opined that “medical spine care is the poster child of inefficient spine care.”[4]

Say No to Drugs

For the sake of the WCA board, let’s review the plethora of anti-painkiller articles recently in the media concerning the recent onslaught of prescription narcotic abuse:

Conclusion. The effectiveness and safety of long-term opioid therapy for treatment of CLBP remains unproven.[5]

“Results showed that 12% of the adults reported personally struggling with opioid dependence, which the surveyors point out is more than those who struggle with diabetes (7%) or cancer (3%).”[6]

“It's like giving a football player painkillers so he can finish the game. It gets him back on the field, but might hurt him worse in the long term.”[7]

The Drug Enforcement Administration’s probe began after attorneys representing about 1,300 NFL retirees filed a lawsuit accusing the league of illegally handing out painkillers, sleeping pills, and other drugs without informing players of the risks of health problems and addiction. 

Former Chicago Bears quarterback Jim McMahon and other plaintiffs accuse the NFL of illegally providing prescription drugs without telling players about the risks. McMahon says he became hooked on pain pills, at one point gulping down more than 100 Percocets each month.[8]

  • Placebo OTC meds: Although most guidelines recommend OTCs before opioids for CLBP, apparently they are not without their own consequences, such as being ineffective and the leading cause of liver damage.

Recently a multicenter, “double-dummy”, randomized, placebo controlled trial by Prof. Christopher G Maher, PhD, et al. across 235 primary care centers in Australia was published in The Lancet and confirmed a commonly used treatment for acute LBP, paracetamol, aka, acetaminophen (Tylenol, Panadol), was no better than placebo:

“Our findings suggest that regular or as-needed dosing with paracetamol does not affect recovery time compared with placebo in low-back pain, and question the universal endorsement of paracetamol in this patient group.”[9]

Acetaminophen overdose results in more calls to poison control centers in the US than overdose of any other pharmacological substance.[10] Almost 80,000 people per year are treated in emergency rooms because they have taken too much, and the drug is now the most common cause of liver failure in this country.[11]

“The definition of success did not consider pain relief or opioid medication use. Even among the patients classified as having a successful result, most were still using narcotic medications at the 2-year follow-up, including 64% of the successful-result patients in the disc replacement group and 84% in the fusion group.”[17]

“…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…”

It also mentions grave concerns about the small improvement after back surgery:

“Some studies have shown no benefit of surgery compared with intensive interdisciplinary rehabilitation, with a significant proportion of patients experiencing suboptimal outcomes, including persistent pain or functional deficits after surgery.”

On the basis of the evidence, Dr. Chou said, they were unable to give strong recommendations for surgery, "but we think there may be some patients for whom surgery, fusion specifically, might be helpful, but it's really important for doctors to discuss the fact that surgery doesn't tend to lead to huge improvements on average. You're talking about a 10- to 20-point improvement in function on a 100-point scale, so that's pretty small, and a significant proportion of patients still need to take pain medication and don't return to full function."[18]


EXECUTIVE SUMMARY

The United States is in the midst of an unprecedented drug overdose epidemic.

Drug overdose death rates have increased five-fold since 1980. By 2009, drug overdose deaths outnumbered deaths due to motor vehicle crashes for the first time in the U.S. Prescription drugs, especially opioid analgesics, have been increasingly involved in drug overdose deaths. Opioid analgesics were involved in 30% of drug overdose deaths where a drug was specified in 1999, compared to nearly 60% in 2010. Opioid-related overdose deaths now outnumber overdose deaths involving all illicit drugs such as heroin and cocaine combined. In addition to overdose deaths, emergency department visits, substance treatment admissions and economic costs associated with opioid abuse have all increased in recent years.

We Have Your Back

These numerous studies and reports prove without a reasonable doubt that the medical spine care train has been a failure. Instead of standing back while patients are taking a Wild Ride on the Medical Railroad, isn’t it time the chiropractic profession jumped on the “Just Say No to Drugs” bandwagon by positioning ourselves as the primary non-drug spine providers? Since the medical society, the AMA, or Big Pharma are not warning patients, we would be the lone voice in this epidemic of failed medical spine treatments. We need to position ourselves as the much maligned scapegoat by an unethical medical monopoly. We now have risen from the ashes of defamation to prevail and bring to the public the best in spine care without drugs, shots, or surgery--this is the story we need to tell.

This should be our strategic advantage nowadays since Americans have been duped by their MDs and Big Pharma and the tide is finally turning against them in the arena of narcotic painkillers. Indeed, how many more patients must die or become addicted before the chiropractic profession finds the backbone to speak out on this “national scandal”? We know for sure Sanjay Gupta will never tout our drug-free position, so we must do it ourselves.

Drugs associated with Back Pain

The following 100+ medications are used in some way in the treatment of back pain.


Examples of nonprescription pain medications include:

 

    Acetaminophen (Tylenol)

    Aspirin

    Ibuprofen (Advil, Motrin IB)

    Naproxen (Aleve)

 

Examples of prescription medications include the following:

 

Nonsteroidal anti-inflammatory drugs (NSAIDs)

    Diclofenac (Voltaren)

    Diflunisal (Dolobid)

    Etodolac (Lodine)

    Fenoprofen (Nalfon)

    Flurbiprofen (Ansaid)

    Ibuprofen (Motrin)

    Indomethacin (Indocin, Indo-Lemmon)

    Ketorolac (Toradol)

    Mefenamic acid (Ponstel)

    Meloxicam (Mobic)

    Nabumetone (Relafen)

    Naproxen (Naprosyn, Anaprox)

    Oxaprozin (Daypro)

    Piroxicam (Feldene)

    Sulindac (Clinoril)

    Tolmetin (Tolectin)

 

COX-2 inhibitor

    Celecoxib (Celebrex)

 

Opioid analgesics

    Acetaminophen with codeine (Tylenol #2, #3, #4)

    Buprenorphine (Butrans)

    Fentanyl transdermal patches (Duragesic)

    Hydrocodone with acetaminophen (Lortab Elixir, Vicodin)

    Hydrocodone with ibuprofen (Vicoprofen)

    Hydrocodone (Zohydro)

    Hydromorphone (Exalgo)

    Meperidine (Demerol, Merpergan)

    Methadone (Dolophine)

    Morphine and morphine sustained release (MS-Contin, Avinza, Kadian)

    Oxycodone sustained release (OxyContin)

    Oxycodone with acetaminophen (Percocet)

    Oxycodone with aspirin (Percodan)

    Oxycodone with ibuprofen (Combunox)

    Oxymorphone (Opana, Opana ER)

    Pentazocine (Talwin,)

    Propoxyphene with aspirin, propoxyphene with acetaminophen

    Tapentadol (Nucynta, Nucynta ER)

    Tramadol, tramadol with acetaminophen (Ultram, Ultracet)

 

Mixed opioid agonist/antagonists

    Pentazocine/naloxone (Talwin NX)

    Butorphanol

    Nalbuphine (Nubain)

 

Antidepressants

    Amitriptyline (Elavil)

    Bupropion (Wellbutrin)

    Desipramine (Norpramin)

    Duloxetine (Cymbalta)

    Imipramine (Tofranil)

    Venlafaxine (Effexor)

 

 

Anticonvulsants

    Carbamazepine (Tegretol)

    Clonazepam (Klonopin)

    Gabapentin (Neurontin)

    Lamotrigine (Lamictal)

    Pregabalin (Lyrica)

    Tiagabine (Gabitril)

    Topiramate (Topamax)

 

Fibromyalgia medication

    Milnacipran (Savella)

 

Anxiolytics

    Alprazolam (Xanax)

    Diazepam (Valium)

    Lorazepam (Ativan)

    Triazolam (Halcion)

 

Muscle relaxants

    Baclofen (Lioresal)

    Carisoprodol (Soma)

    Chlorzoxazone (Parafon Forte, DSC)

    Cyclobenzaprine (Flexeril)

    Dantrolene (Dantrium)

    Metaxalone (Skelaxin)

    Methocarbamol (Robaxin)

    Orphenadrine (Norflex)

    Tizanidine (Zanaflex)

 

Corticosteroids

    Cortisone

    Prednisone

    Prednisolone

    Dexamethasone

    Methylprednisolone (Medrol, A-Methapred, Depo Medrol, Solu Medrol)

    Triamcinolone (Allernaze, Aristospan 5 mg, Aristospan Injection 20 mg, Kenalog 10 Injection, Kenalog Nasacort AQ)

 

Is the study of pain pharmacology really worth the effort considering the dangers and ineffectiveness?  Instead of studying pain medications, our time will be better served implementing the CAM ‘best practices’ for the pandemic of back pain, the #1 disabling condition in the nation, the military, and in the world.

Bigger Battles:

Rather than going to the mattresses over the prescription rights debate to resemble osteopaths, if the WCA wants to “advance” our profession, let me suggest a few more important battlegrounds:

  1. Fighting for unencumbered access: VA patients now must jump over hurdles to get to DCs who are then handcuffed with a grossly unfair and arbitrary number of eight office visits and the types of services we can use. If the VA Reform is to offer a “Choice Card,”  we must be the main choice for LBP.
  2. Confront the perverse motivation: The prevailing Jim Crow, MD’s segregation attitude in state and federal Workers Comp programs and in hospitals have severely restricted injured patients’ right to use our services thereby forcing them into unnecessary drugs, shots, and spine surgeries as well as increasing costs to employers.
  3. Expand our scope and treatments in Medicare: It is unconscionable that Medicare refuses to pay for CLBP considering chronic LBP is the leading disability in our country. The fact that we are only allowed to “correct vertebral subluxations” is antiquated in today’s marketplace and stinks of restriction of free enterprise. Obviously the Committee on Quackery’s old wither on the vine’ policy  is still in effect in Medicare.
  4. Publicity in the earned media: Indeed, when was the last time you’ve seen on television an in-depth article about the benefits we bring to the epidemic of back pain? Okay, stop laughing because it just doesn’t happen. We need to tout our benefits to overcome the prevailing chirophobia in the media
  5. Pop & Pot Chiropractic: If DCs in the WCA want to prescribe anything, I suggest they push for the legalization of medical marijuana! A recent study published in JAMA, Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010,  discovered that states with medical pot have 25% less deaths from painkiller overdoses.[19]

Perhaps the WCA should conduct a comparative study for “best weapons” using chiropractic care and medical marijuana versus standard MD/PT care consisting of OTC meds, muscle relaxors, prescription painkillers, and standard physiotherapeutics to determine which brand of weapons perform best of all. I daresay there would be no contest for patients suffering from CLBP.

Indeed, if we are going to the mattresses, let’s at least fight together to expand our market, improve our image, and provide services that are safe as well as cost and clinically-effective.

Advancing Chiropractic: Which Battle?

Dr. Lefler opines, “With the exception of chiropractic, every other health care profession is advancing its training and setting the stage for winning the battle.” We should champion drug-less healing rather than running away from it as if we were at a disadvantage.

To the contrary, I seriously disagree that the inclusion of prescription drugs or minor surgery in our profession “is advancing its training and setting the stage for winning the battle” since the real battle now is to be won in the media, not in the drugstore.

Now is the time we should be advocating a drug-less approach since opioids are finally getting much-deserved bad press. It’s only taken twenty years for this bad news on painkillers to go viral; will it take another twenty years before the good news about chiropractic care goes viral, too?

Instead of jumping on the narcotic bandwagon with the medical drug cartel, if there ever has been a golden opportunity for the chiropractic profession to promote itself as a drug-less treatment for the epidemic of back pain, the main malady driving people to narcotics, now is the time to speak up.

Gupta’s Gaffe

One opportunity was missed when Sanjay Gupta of CNN aired his program, Deadly Dose, on the abuse of opioids. Ostensibly, he was searching for a non-drug treatment for CLBP, but failed to mention chiropractic, the third-largest physician-level profession in the country that specializes in back pain treatment.

Imagine if Gupta had had the journalistic integrity to announce on his program that millions of Americans suffering from CLBP could be helped without narcotic painkillers, ESIs, or spine surgery, what a boon that would have been.

Instead, Dr. Gupta’s bias and professional amnesia illustrated that a neurosurgeon sponsored by Big Pharma will never tell the public that chiropractic is the treatment of choice for this pandemic of pain. Although he’s quite apologetic now about his condemnation of weed, he still cannot bring himself to apologize for his ignorance about chiropractic care.

This is the medical battle we now fight in the media to get our story out. Our battle is not about prescription rights as a weapon in the medical war against chiropractors, it remains a media war. In fact, it has been since 1930 when Morris Fishbein, MD, Executive Director of the AMA, jumped into bed with Big Tobacco to fund his war chest to destroy chiropractic.

      In  the 1960s, the Committee on Quackery employed third-party authors/writers that included syndicated columnist Ann Landers to defame our profession. Today there are many MD reporters like Sanjay Gupta who apparently want people to live in pain, on narcotics or undergo unnecessary spine surgery than to to a chiropractor.

If we are to rehabilitate the contrived negative stigma formed by this Medical Mussolini, it requires more than prescription rights, minor surgery, or disseminating WOC print ads featuring sport celebrities.

We could not have asked for a better time to go on the PR offensive in light of the recent government announcements and news articles that denounce the Hillbilly Heroin opioid epidemic, the flood of expensive, ineffective epidural steroid shots, and spine surgeries based on disproved ‘bad disc’ and pathoanatomical diagnoses now deemed “incidentalomas.”

The public already knows we are drug-less and, rather than shying away from that fact, the tables have turned now and we should shout it from every rooftop. We need a PR publicist to arrange interviews to tell our story.

 

 

The research now clearly supports our case; the guidelines all recommend conservative care before drugs, shots, or surgery, and the public satisfaction polls show our clinical effectiveness.

Mark my word but hopefully sooner than later medical spine care, the so-called ‘poster child of inefficient spine care’ will be known as the biggest scam in medical care, affecting millions of Americans and costing billions of dollars in wasted drugs, shots, and surgeries.

I cannot overemphasize the need to choose our battles, to end the prescription drug debate, improve our ‘best practices’ protocols, and to redesign our PR efforts from paid ads to earned media with spokes-persons who can tell our fascinating story from persecution to vindication.

Indeed, let’s show the nation why chiropractic is ranked the 11th best job in America.[20]


JC Smith, MA, DC, is a 35-year practicing chiropractor, author of The Medical War Against Chiropractors, and he maintains a popular website, Chiropractors for Fair Journalism.



[1] 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

[2] 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

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

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

[5] Luis Enrique Chaparro, MD, Andrea D. Furlan, MD, PhD, Amol Deshpande, MD, Angela Mailis-Gagnon, MD, MSc, FRCPC, Steven Atlas, MD, Dennis C. Turk, PhD, Opioids Compared With Placebo or Other Treatments for Chronic Low Back Pain, An Update of the Cochrane Review, Spine. 2014;39(7):556-563

[6] Deborah Brauser, Many Docs Still Don't Understand Opioid Dependence, www.medscape.com Jun 14, 2013

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

[8] Michael O’keeffe, EXCLUSIVE: Feds quietly investigating prescription drug abuse in NFL locker rooms, sources say, NEW YORK DAILY NEWS, Saturday, July 12, 2014

[9] Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial, Dr Christopher M Williams PhD, Prof Christopher G Maher PhD, Prof Jane Latimer, Prof Andrew J McLachlan PhD, Mark J Hancock PhD, Prof Richard O Day MD, Chung-Wei Christine Lin PhD, The Lancet, Early Online Publication, 24 July 2014 doi:10.1016/S0140-6736(14)60805-9

[10] Lee WM (2004). "Acetaminophen and the U. S. Acute Liver Failure Study Group: lowering the risks of hepatic failure". Hepatology 40 (1): 6–9. doi:10.1002/hep.20293. PMID 15239078.

[11] Special report: The dangers of painkillers, Consumers Report, July 2014

[12] Leite FM, Atallah AN, El Dib R, Grossmann E, Januzzi E, Andriolo RB, da Silva EM, Cyclobenzaprine for the treatment of myofascial pain in adults. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD006830. doi: 10.1002/14651858.CD006830.pub3

[13]Epidural Corticosteroid Injection: Drug Safety Communication - Risk of Rare But Serious Neurologic Problems,” FDA, April 23, 2014

[14] 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 J Silberner, “Surgery May Not Be The Answer To An Aching Back,”  All Things Considered, NPR (April 6, 2010:907-31.

[17] Mirza, Sohail K. MD, MPH, Point of View: Commentary on the Research Reports that Led to Food and Drug Administration Approval of an Artificial Disc, Spine: 30(14) 15 July 2005 pp 1561-1564.

[18] Low Back Pain Guidelines Expanded to Include Interventional Procedures, American Pain Society 27th Annual Scientific Meeting: Symposium 312. Presented May 8, 2008

[19] Marcus A. Bachhuber, MD; Brendan Saloner, PhD; Chinazo O. Cunningham, MD, MS; Colleen L. Barry, PhD, MPP, Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010, JAMA Intern Med. Published online August 25, 2014.

[20] Joe Light, “The Best and Worst Jobs,” The Wall Street Journal, (January 4, 2011)



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