Articles by JCS

Uncle Sam Needs You

                                                                                                                          

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“We Must and Can Do Better”

CHIROPRACTORS:

UNCLE SAM NEEDS YOU!

Scrutiny into the Department of Veteran Affairs (DVA) continues to grow after efforts to reform the DVA by the former Secretary of Veterans Affairs, Eric Shinseki,  were deemed “a stunning period of dysfunction” by Senate Minority Leader Mitch McConnell, (R-KY).

Controversial issues range from cooked books to cover up protracted delays causing deaths at Veterans Affairs hospitals, insufficient patient care personnel, unwarranted staff bonuses, and punishment of whistle-blowers.

According these reports, Congressmen now investigating this complex DVA dysfunction have suffered from sticker shock at the cost of $35 billion through 2016, and thereafter would be $50 billion a year to care for the 6.5 million vets seeking VA treatment every year.[1] More alarming corruption was found within the veterans' health care system overpaying some 13,000 clerks, administrators, and other support staff.[2]

Pill Mill Military

Adding to the many administrative issues and exploding costs in the DVA, reports have recently exploded in the media about the pandemic of chronic pain and the addiction to prescription painkillers like OxyContin, Hydrocodone, and Percocet indiscriminately handed out like Halloween candy to active duty military and veterans alike.

“They'd just shove you a bag of pills,” said one veteran addicted to painkillers. “No matter what you needed, there was a pill. Everything under the sun, from Adderall to Percocet to hydrocodone, oxycodone, you name it."[3]

This shocking news recently surfaced with a two-segment exposé on NPR’s All Things Considered about the growing narcotic painkiller addiction among active military and veterans, Veterans Kick The Prescription Pill Habit, Against Doctors' Orders, and A Growing Number Of Veterans Struggles To Quit Powerful Painkillers.

 These radio broadcasts revealed the VA this year will treat about 650,000 veterans with opiates over the growing complaints of patients. One in 3 veterans polled say they are on 10 or more different medications. [4]

Abuse of prescription drugs is also high among Active Duty Service Members. On average, ADSM are prescribed narcotic painkillers three times more often than civilians.[5]

Dr. Richard Friedman, director of the Psychopharmacology Clinic at Weill Cornell Medical College, spoke of the ‘pill mill’ mentality in the military. “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.”[6]

The tsunami of painkillers is also a factor in the high rate of veteran suicide according to Dr. Gavin West who heads the Opioid Safety Initiative at the VA. "It's a national problem," and he says the VA is trying to change its approach and stop offering opiates as a first option for pain.[7]

“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.”

Notably missing from this “large arsenal” is any mention of chiropractic care that has already been shown to be more beneficial and, most of all is drug-free. Unquestionably, the best complimentary and alternative medical (CAM) treatments for spine-related disorders are Chiropractic, Acupuncture, and Massage Therapy.

In conjunction with opioid painkillers, pain management clinicians also use controversial epidural corticosteroids injections (ESIs) that have been shown to be no better than placebo[8] and 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, (FDA, April 23, 2014).

In another 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.”[9]

D.J. Aldington, advisor to the UK's surgeon general from Churchill Hospital in Oxford, England, wrote in his Invited Commentary, Back Pain: The Silent Military Threat: Comment on “Back Pain During War of the importance to study chronic pain and use of opioids that carry the risk of functional impairment of America’s fighting force.[10]

"The importance of the medically 'mundane' condition of low back pain cannot be overstated," he said, acknowledging that the condition is often overshadowed by the more traumatic injuries of war.

"In many ways this parallels the experience in civilian life where the organization of services and treatments for low back pain are particularly chaotic despite the huge impact it has on society as a whole."

Other prominent medical ethicists are now speaking out on the chaotic ‘pill mill’ approach to chronic pain management. Thomas Frieden, MD, director for the CDC, minced no words in a news release when he said, “physicians have supplanted street corner drug pushers as the most important suppliers of illicit narcotics.”[11]

Mark Schoene, associate editor of THEBACKLETTER, a leading international spine research journal deems the rash of drugs, shots, and spine surgery as the “poster child of inefficient spine care.” He also states that “such an important area of medicine has fallen to this level of dysfunction should be a national scandal.”[12]

It’s not only a nation-wide public scandal, but now a world-wide military scandal, too.

Back Pain #1 Disability for Active Military

The DoD readily admits that 20% of their disabled vets and 30% of hospitalizations stem from low back pain that has become the largest disabling condition among active forces. According to research done 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.”[13]

A 2010 Johns Hopkins study found that the top reasons for medical evacuation from Iraq and Afghanistan are musculoskeletal disorders, not combat injuries. In a report, 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, compared to 14% who had suffered combat injuries.

Colonel Steven P. Cohen, MD, found only 13% of service members who left their units with back pain as their primary diagnosis eventually returned to duty in the field.  He admits, “If you have only a 13 percent success rate, this is a failure. There’s a systemic problem…Back pain has notoriously low success rates for treatment.”

Dr. Cohen should have been more specific by stating “notoriously low success rates for medical treatment,” the typical arsenal of opioid painkillers, epidural steroid injections, physiotherapeutics, and spine fusions.

Dr. Cohen suggests the biggest predictors of a poor outcome are “psychosocial factors” which certainly play a minor role. However, a compelling case can be made that a significant predictor for poor outcomes is the shortage of chiropractors (DCs) to treat soldiers who routinely tote 80-pound backpacks on field duty.

Chiropractic: Treatment of Choice

The benefit of chiropractic care is certainly not a new revelation. Twenty years ago in 1994, the Agency for Health Care Policy & Research investigated the epidemic of back pain and at the top of its treatment algorithm rated spinal manipulation as a ‘proven treatment’ for acute low back pain in adults.[14]

An editorial in the Annals of Internal Medicine published jointly by the American College of Physicians and the American Society of Internal Medicine (1998) also noted that “spinal manipulation is the treatment of choice” and mentioned, “Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement.”[15]

The paradigm shift in spine care now emphasizes joint dysfunction, not ‘bad discs,’ as the primary cause of low back and neck pain. Although back pain can have different causes helped by various spine professionals, such as the rare case of disc derangement, radiculopathy, and muscle trigger points, but the single-largest source of pain is due to joint dysfunction. 

Two recent 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.[16],[17] Considering there are over 300 joints in the entire spinal column[18], this should not come as a surprise why spinal manipulative therapy (SMT) is considered the leading treatment in the majority of cases.

For example, a recent 2012 study from Washington state workers comp compared patients with low back pain whose primary spine provider was a chiropractor or a medical doctor determined drastically different rates for surgery—42.7% of workers who first saw an MD had surgery in contrast to only 1.5% of those who saw a chiropractor.[19]

Great Opportunity for Improvement

Acting Secretary Sloan Gibson recently told the Senate Veterans Affairs Committee it will take two years, 1,500 more doctors and more than $17 billion in taxpayer money to fix the problems plaguing the VA. “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.” [20]

With these hopeful declarations in mind, my suggestion to Sec. Gibson is to hire more Doctors of Chiropractic as primary spine providers to manage the pandemic of back pain cases without drugs, shots, or surgery. Simply adding more MDs and DOs with the same ‘pill mill’ 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.”

Positive Findings in Military Low-Back Pain Study

Where chiropractic care has been used in the military health services, it has been deemed very successful. A recent study led by Christine Goertz, DC, PhD, that 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.[21]

The Goertz study followed the DoD’s Chiropractic Care Study released in 2009 when chiropractic care was selectively introduced at a few TRICARE facilities with chiropractors as the primary spine providers as researchers now suggest.[22]

The results were impressive across all branches of the military when chiropractors scored enormously high patient satisfaction rates that ranged from:

  • 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.[23]

The Chiropractic Care Study also revealed praise from Unit Commanders, ADSM, and military treatment facilities (MTF) personnel concerning chiropractic care. Overall, the Chiropractic Care Study showed that MTFs consider chiropractic care a “valuable adjunct” to the care offered in the MTFs. “Chiropractors returned ADSMs to duty faster, and they would select a chiropractor as much or more than a Doctor of Osteopathy or physical therapist.” [24]

Despite these good results, the military health services have not fully implemented chiropractors on all bases and at all VA hospitals as called for by federal law. Ironically, the military medical corps has no problem plying ADSM or vets with narcotics while deterring full access to more effective and drug-less chiropractic care.

Chiropractic Demonstration Project Conflict

President Ronald Regan initiated chiropractic inclusion in TRICARE in 1984, but its implementation was stymied for years by political medicine whose stated goal was to “contain and eliminate chiropractic.” A federal antitrust court described this conspiracy as “systematic, long-term wrongdoing, and the long-term intent to destroy a licensed profession.”[25]

Finally to push the DoD to take action, the National Defense Authorization Act for Fiscal Year 1995 mandated that Congress undertake a demonstration project to determine the cost effectiveness of adding chiropractic care in the military health services.

The DoD began a three-year demonstration project (Aug. 1995 to Aug. 1998) at 13 military sites to care for their military personnel that became known as the Chiropractic Health Care Demonstration Program (CHCDP).

When the results were tallied, the House and Senate Armed Services Committees stated that chiropractic care in the military was "well-received," and "complemented and augmented traditional medical care."

Inexplicably, the analysis of senior management at the DoD of the CHCDP Final Report (February 20, 2000) came to an opposing conclusion when it reported the inclusion of chiropractic care in the MHS was “feasible” but “not advisable” because of the costs associated with chiropractic care. 

Upon closer examination, however, the DoD’s version of the CHCDP Final Report only reported ‘raw costs’ of $70.9 million for an unconstrained chiropractic benefit and chose not to include any of the cost savings and offsets the CHCDP study identified.

However, the Minority CHCDP Final Report (March 3, 2000) written by the Oversight Advisory Committee headed by Reed Phillips, DC, PhD, adjusted the ‘raw cost’ figure of $70.9 million given by DoD by using savings and cost offsets noted but not factored into their cost estimate in the DoD CHCDP Final Report. 

The Minority Report estimated that the inclusion of chiropractic care in the MHS would result in significant net savings of $25.8 million annually in “improved outcomes” and would also save 199,000 labor days.

The areas of savings/cost offsets were noted as:

  • $18,973,000 saved costs for PT care of back pain                          

  • $6,700,000 saved costs with reduction of inpatient events with DC care.                        

  • $27,824,000 estimated value of 199,000 duty/labor days saved with DC care.                

  • $11,328,000 estimated savings from eliminated health services of DME, Home Health, Hospice, etc. with chiropractic care.

  • $31,917,000 estimated additional savings of PT substitution due to reduced ER and PCP visits and other cost savings.

  • All tolled, this equates to a net annual savings of $25.8 million.

 

Overcoming Military Barriers

Obviously the DoD’s interpretation of the CHCDP Report was purposely skewed to misrepresent the findings of this three-year study. Similar interference continues to this day despite federal laws calling for the total inclusion of DCs in TRICARE and DVA, the both military health services still have not fully included chiropractors for reasons that remain speculative.

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 the DoD health care system for active-duty military personnel, TRICARE. Similarly, (Public Law 107-135) was enacted in 2001 and provided for the availability of chiropractic care within the DVA health system.

Since the clinical outcomes, high patient satisfaction surveys, and favorable accounting at MTFs fully support the inclusion of chiropractic care, one can only assume the problem rests with the historical prejudice from political medicine against chiropractors.

This dilemma surfaced in my communication in 2010 with senior management at the DoD, S. Ward Casscells, MD, the Assistant Secretary of Defense Health Affairs and Mr. Michael W. O’Bar, his Deputy Chief, TRICARE Policy and Operations.

In Mr. O’Bar’s letter of December 6, 2010 to me, he explained the rationale why chiropractic care is not fully available to all TRICARE recipients as the law calls for:

“In addition, adding chiropractic care to the primary care model was estimated to increase the number of visits per episode of care. Ultimately, this increases the costs and delays a service member’s return to duty. These constraints have limited our ability to field chiropractic care beyond the 60 locations currently providing the service.”

His answer contradicts the data not only from the CHCDP Final Report, but also from two additional reports that he sent to me: the Chiropractic Care Study and the “Report to Congress, Study Relating to Chiropractic Services and Benefits, Section 712, National Defense Authorization Act for FY07.”

Dr. S. Ward Casscells also mentioned in his cover letter of March 3, 2009 to Sen. John Murta that “a comprehensive implementation of chiropractic services and benefits as outlined in the provision would not be feasible given the budgetary requirements and the findings relative to medical readiness.”[26] To the contrary, the CHCDP already had showed the potential cost savings by implementing chiropractic care.

Dr. Casscells also speculated that chiropractic care “delays a service member’s return to duty” and he further suggested, “in the absence of chiropractic care, various comparative treatment options are available to Active Duty Service Members (ADSM), their families, and other beneficiaries of the Military Health System.”

However, upon review of the DoD study, Dr. Casscells’ conclusions also contradict the clinical results and the preference of patients for DCs:

“Overall, the surveys showed that MTFs consider chiropractic care a valuable adjunct to the care offered in the MTFs. Unit personnel generally consider chiropractors to return ADSMs to duty faster, and they would select a chiropractor as much or more than a Doctor of Osteopathy or physical therapist.” [27]

Dr. Casscells’ incorrectly assumes that osteopathic, medical, or physical therapy is a “comparable treatment” to chiropractic care. In fact, evidence now shows chiropractic is the preferred initial non-drug treatment and that most MDs, DOs, and PTs do not have equivalent education, clinical training, or comparable outcomes to DCs in regards to musculoskeletal disorders (MSDs) and, specifically, back pain.

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.”[28]

Other research shows that medical primary care physicians lack training in MSDs,[29] are more prone to ignore recent guidelines,[30] more likely to suggest spine surgery than surgeons themselves,[31] and only 2% of medical PCPs refer to DCs despite their superior training and results.[32]

As well, a federal court agreed that it is unreasonable to state that non-chiropractors are qualified to render chiropractic care. In its Dec. 13, 2005 decision, the three-judge Appeals Panel overturned the ruling of the District Court in the District of Columbia allowing MDs and DOs to provide the uniquely ‘chiropractic service’ in Medicare. [33] The appeals panel ruled the issue is whether or not a practitioner is qualified to furnish the service of manual manipulation of the spine rather than whether or not a practitioner is simply licensed.

Another barrier in TRICARE is the subordination of chiropractors to PTs who are presently in charge of DCs despite PTs being ranked as technicians by both the DoD and the VA. This is equivalent to sergeants in control of officers since PTs are therapists whereas DCs are considered physicians.

“Just Say No”

Undoubtedly the benefits from chiropractic care have been stymied by medical opposition in the DVA and TRICARE that irrefutably has led to the present ‘pill mill’ pain management crisis.

This problem rests with the combination of the historical medical war against chiropractors, medical ignorance of or defiance to the new guidelines in spine care, and the prevailing prejudice against chiropractors, a bias dubbed ‘chirophobia.’

However, the voices of change in healthcare are louder today unlike before when chiropractors initially stood alone demanding access to patients in the military health services. Since then this voice has been joined by members of Congress, the ADSM, as well as our veterans who need chiropractic care.

Now we hear the progressive voices in the medical world that are joining this choir calling for a change in the management of chronic pain and MSD injuries.

Dr. Jonas speaks of the need for a “cultural transformation;” Sec. Gibson believes “we must, all of us, seize this opportunity;” Mr. Schoene speaks of the “national scandal” in medical spine care;” and Dr. Aldington believes “the importance of the medically 'mundane' condition of low back pain cannot be overstated;" and Dr. Cohen admits, “We must and can do better.”

When the military health services want to do better, it’s time for both the DVA and DoD to “Say No to Drugs” and to “Say Yes to Chiropractors” who offer a non-drug and proven treatment for back pain.[34]

If our military personnel are to receive the best of spinal care to avoid work disability, loss of quality of life, permanent impairment, and possible addiction to painkillers, or worse—suicides and accidental deaths from opioids—it is imperative the DVA and DoD fully institute the “best practices” for our ADSMs and vets and stop with its outdated policy to limit, substitute, boycott, or subordinate chiropractors.

 

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



[1] Lawmakers Slam Veterans Health Bill Cost Estimate: By David Lawder, Reuters,  June 24, 2014

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

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

[5] ibid.

[6] ibid.

[7] ibid.

[8] 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

[9] 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

[10] Arch Intern Med. 2009;169 (20):1923-1924. 

[11] 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.

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

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

[14] 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)

[15] MS Micozz,  “Complementary Care: When Is It Appropriate? Who Will Provide It?” Annals of Internal Medicine 129/1  ( July 1998):65-66

[16] 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

[17] 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

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

[19] Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KC, Franklin GM., Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State.,Spine (Phila Pa 1976). 2012 Dec 12.

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

[21] Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients With Acute Low Back Pain: Results of a Pragmatic Randomized Comparative Effectiveness Study, Goertz, Christine M. DC, PhD, et al., Spine:

15 April 2013 - Volume 38 - Issue 8 - p 627–634

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

[23] 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.

[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): p. 3.

[25] Associated Press, “U.S. Judge Finds Medical Group Conspired Against Chiropractors,” New York Times (1987)

[26] S. Ward Casscells, MD, cover letter to John Murtha, March 3, 2009.

[27] 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.

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

[29] 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).

[30] 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.

[31] 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.

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

[33] Michael Devitt, “Landmark Decision in ACA Lawsuit Against HHS,” Dynamic Chiropractic 24/02 (January 15, 2006)

[34] 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)


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