Articles by JCS

Washington Awakens

                                                                                                                                            

Word count: 5482

Washington Awakens

“There is a smoking gun and it is the prescription pad.
The training and the ammunition is provided by the pharmaceutical companies.”

Robert Lynch, DC,

 Maine Board of Chiropractic Examiners

Rosa Parks, the patron saint of the civil rights movement, ignited this country’s sensibility to discrimination by simply refusing to move to the back of the bus. Certainly by now chiropractors feel the same frustration of being thrown under the medical bus during the last century while offering a nondrug solution to the pain pandemic.

Even harder for the government officials will be watching MDs driving this broken down medical bus filled with addicted passengers supposedly in a new direction away from opioids, but not necessarily to the chiropractors’ offices.

Despite the inaction by the Do-Nothing Congress, a few federal agencies, non-governmental organizations (NGO) and the White House have finally examined the issues of chronic pain and the growing prescription opioid painkiller problem after nearly a half million Americans have needlessly died from narcotic painkillers. Better late than never as usual for Washington DC.

Maybe there is hope this broken medical bus can find a new driver to steer people away from drugs, but as long as Big Pharma and the AMA fuel this bus by wielding financial power on Capitol Hill, there will be road blocks and long delays to keep the status quo.

Despite these obstacles from organized medicine, here are a few of the major studies since 2009 on chronic pain and the opioid epidemic:

  • VA/DoD: Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, 2009.[1]
  • Office of the Army Surgeon General: Pain Management Task Force; Final Report, May 2010.[2]
  • Institute of Medicine (IOM): “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,”[3] 2011.
  • National Institutes of Health: Report of the Task Force on Research Standards for Chronic Low Back Pain, 2014.[4]
  • National Institute on Drug Abuse:America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,” 2014. [5]
  • National Institute on Drug Abuse: Prescription Drug Abuse, 2014.[6]
  • Health and Human Services: “Opioids: The Prescription Drug & Heroin Overdose Epidemic,” 2015.[7]
  • Surgeon General:  “Report on Substance Use, Addiction, and Health,” 2015.[8]
  • Health and Human Services: National Pain Strategy: “A Comprehensive Population Health-Level Strategy for Pain,” 2015.[9] 
  • American Public Health Association (APHA): "Prevention and Intervention Strategies to Decrease Misuse of Prescription Pain Medications," 2015.[10]
  • Substance Abuse and Mental Health Services Administration: “Opioids”, 2016.[11]
  • The Joint Commission: “Clarification of the Pain Management Standard,” 2016.[12]
  • Centers for Disease Control: Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.[13]
  • White House FACT SHEET: “President Obama Proposes $1.1 Billion in New Funding to Address the Prescription Opioid Abuse and Heroin Use Epidemic,” 2016.[14]
  • FDA: “A Proactive Response to Prescription Opioid Abuse,” 2016.[15]
  • Agency for Healthcare Research and Quality: “Noninvasive Treatments for Low Back Pain,2016.[16]
  • National Governors Association: “Governors’ Priorities for Addressing the Nation’s Opioid Crisis,” 2016.[17]
  • Bone & Joint Initiative:The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost,” 2016.[18]

The consensus was clear:

  • too many opioids,
  • too many promiscuous prescribers,
  • general physicians uneducated in chronic pain management, and
  • the need for nondrug alternatives for care.

Centers for Disease Control and Prevention

Due to the growing opioid epidemic, the CDC decided to recommend what the AMA and Big Pharma refused to do – control the pandemic of narcotic painkillers with its “Guideline for Prescribing Opioids for Chronic Pain – United States, 2016.”[19] The Guideline is not a federal regulation and adherence to the Guideline will be voluntary, which is the biggest loophole yet. In other words, this Guideline is toothless.[20]

Of course, immediately the medical industrial complex opposed the CDC Guideline. Indeed, nothing changes in Washington without the approval of special interest groups and that includes the AMA and Big Pharma, the very groups who created this opioid mess.

Since MDs have caused this pandemic of opioid poisoning by showing little restraint, the CDC was on track to finalize new prescribing guidelines for opioid painkillers in January 2016. The guidelines – though not binding – would be the strongest government effort yet to reverse the rise in deadly overdoses tied to drugs like OxyContin, Vicodin and Percocet — among the usual suspects of medicinal heroin medications.

The intended target group of the CDC Guideline is primary care providers and the focus is opioid prescribing for adult patients with chronic pain. The recommendations apply to management of common problems such as back pain and arthritis pain. They do not address pain management in patients being treated for life-threatening diseases such as cancer, post-surgical or patients at the end of life.[21]

“It’s the first time the federal government has clearly communicated to the medical community that widespread and routine practice of treating long-term chronic pain with opioids is inappropriate,” said Dr. Andrew Kolodny, the executive director of the Physicians for Responsible Opioid Prescribing.[22]

Unfortunately, the CDC Guideline came up a bit short concerning the best available nondrug solution with no mention of chiropractic care or spinal manipulative therapy:

Contextual evidence is complementary information that assists in translating the clinical research findings into recommendations. CDC conducted contextual evidence reviews on four topics to supplement the clinical evidence review findings:

  • Effectiveness of nonpharmacologic (e.g., cognitive behavioral therapy [CBT], exercise therapy, interventional treatments, and multimodal pain treatment) and nonopioid pharmacologic treatments (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], antidepressants, and anticonvulsants), including studies of any duration.

Under the proposed CDC Guideline doctors would prescribe these drugs only as a last choice for chronic pain, after NSAID painkillers, physical therapy and other “hands-on” options such as physical therapy and CBT. The CDC also wants doctors to prescribe the smallest supply of the opioid drugs possible, usually three days or less for acute pain.

Big Pharma Pushback

The CDC was forced to delay its guidelines until March 15, 2016, following months of lobbying by physician and patient groups aligned with Big Pharma, who always has a seat at the table in federal discussions on painkillers.

As expected, the medical drug cartel opposes the new guidelines. This guideline put the CDC into the middle of a longstanding fight over the use of opioids. Immediately Big Pharma pushed back on the CDC’s guidelines to control prescribers. Of course, the AMA and Big Pharma have no intention to lose this cash cow without a fight.

In its defense, Big Pharma funded bogus advocacy groups to maintain the status quo. The Pain Care Forum is sponsored OxyContin-maker Purdue, whose chief lobbyist created the group and remains at its center. The Pain Care Forum developed its own "consensus guidelines" that essentially opposed any measures creating "new barriers" to medication. Another opponent, the American Academy of Pain Management (AAPM), gets about $300,000 from makers of opioids.[23]

"They're very well-funded and they have a lot of Pharma money behind them," said Dr. Lewis Nelson of New York University, an FDA adviser who is also advising the CDC on its guidelines. "And then you have the anti-addiction groups on the other side, which is clearly much less funded and organized." [24]

"We were stunned. This is a big win for the opioid lobby," said Dr. Andrew Kolodny, co-founder of Physicians for Responsible Opioid Prescribing, a group working to reduce painkiller prescribing.[25]

If the final CDC Guideline emerges intact, they also urge physicians to reconsider alternate treatments beforehand like physical therapy and counseling. Experts admit those methods proved effective before the rise of painkillers. “As a civilization we somehow managed to survive for 50,000 years without OxyContin and I think we will continue to survive,” Dr. Nelson said. [26]

AAPM Snub

Not only did chiropractic get short shrift by the CDC, it was also the elephant in the room at other conferences on chronic pain.

The theme at the 32nd Annual American Academy of Pain Management (AAPM) conference in 2016 was “Ensuring Access to Pain Care: Engaging Pain Medicine and Primary Care Teams” that was “designed for primary care providers (PCPs), advanced practice providers, physical and occupational therapists, clinical and rehabilitation psychologists, nurses, pharmacists, dentists, and other health care professionals who treat, teach, or research the field of pain medicine.”

The AAPM’s brochure[27] mentions after attending the meeting, participants should be better able to:

  • demonstrate the value of a multidisciplinary team approach to the management of acute, chronic, and cancer pain syndromes
  • examine clinical assessment and treatment protocols to improve the treatment of patients with various pain conditions
  • overcome barriers to the implementation of evidence-based strategies that improve the management of chronic pain conditions
  • analyze the use of cost-effective and evidence-based integrative pain management modalities
  • illustrate how to reduce costs, improve efficacy, and use outcome-tracking tools through evidence-based integrative and interventional pain techniques
  • assess evidence-based strategies for chronic pain management
  • discuss the evolution of interdisciplinary pain treatment approaches and describe current and future trends for interdisciplinary care.

Certainly this AAPM brochure used all the politically-correct terms such as the call for “multidisciplinary team” and “evidence-based integrative” to appear progressive, but of the 108 speakers at this AAPM meeting, not one was a chiropractor. Nor was the word “chiropractic” mentioned in its brochure.

The omission of chiropractic care among this field of pain specialists illustrates the intense degree of chirophobia still existing among medical professionals. Considering back pain is the leading cause of chronic pain and opioid use, and chiropractors represent the leading nondrug treatment for this pandemic of back pain, it is shocking chiropractors were not included as speakers or even touted among best solutions for this opioid rampage.

Erin E. Krebs, MD, MPH, is the associate professor of Medicine at the University of Minnesota and core investigator at the Minneapolis VA Center for Chronic Disease Outcomes Research. She spoke at the AAPM conference and made a few remarkable comments on the theme of “ensuring access to pain care”:

“We also need to put opioids in their place. Opioids are only one treatment for pain and probably not the best treatment for most people with chronic pain. If we can ensure all patients with chronic pain are getting optimal non-opioid pain care, our use of opioids will be more targeted and more effective.”[28] 

Dr. Krebs also mentioned the lack of nondrug treatments such as chiropractic spinal manipulation without mentioning it by name:

 “Lack of access to other pain treatments is part of the reason for opioid over-prescribing. We have evidence-based treatments for pain — mostly low tech, high touch treatments — that most people with chronic pain can't access.”[29] 

She finally hit the nail on the head of this opioid pandemic—the “lack of access to other pain treatments.” The lack of access stems from the lack of referrals by MDs to DCs as well as the institutional discrimination in programs such as workers’ compensation and the VA that rarely refers pain patients even though chiropractic care is legally included in these programs.

As the third-largest physician-level profession in the nation, chiropractic is not unknown to these 108 conference speakers, or to the VA and workers’ comp adjusters, but it obviously remains taboo. Indeed, chiropractic remains the proverbial “elephant in the conference room.” Until this medical myopia ends, this opioid pandemic will continue since drugs cannot correct the underlying cause of back pain — joint dysfunction that requires manual methods, not drugs, shots, or surgery.

Not Done Enough

To illustrate the medical myopia on the opioid crisis that MDs themselves created, Patrice A. Harris, MD, MA, a board member with the AMA, told the audience at the American Academy of Pain Medicine's annual meeting, “There's a narrative that physicians have not done enough.”[30]

To the contrary, MDs have done too much promiscuous prescribing and not enough referral to nondrug practitioners. Inexplicably, Dr. Harris, who believes practitioners are doing a lot already to tackle the opioid crisis, along with her colleagues formed the AMA Task Force to Reduce Opioid Abuse.

The task force found that there are several ways for clinicians reverse the nation's opioid epidemic:

  • increase physicians' registration and use of effective PDMPs;
  • enhance physicians' education on effective, evidence-based prescribing;
  • reduce the stigma of pain and promote comprehensive assessment and treatment;
  • reduce the stigma of substance use disorder and enhance access to treatment; and 
  • expand access to naloxone in the community and through co-prescribing.

Although these points are well-intentioned, the elephant in this Task Force recommendations is any mention of nondrug treatments that might actually correct the underlying causes of the patients’ chronic pain problems, most noticeably, chiropractic care considering the majority of cases stem from musculoskeletal disorders.

The AMA’s Task Force is stuck in the “pill for every ill” mindset and cannot understand the majority of chronic pain cases cannot be helped via more narcotic drugs, epidural shots, or the many treatments used by the AAPM members, principally physiatrists and physical therapists who run “pain management” clinics that are renowned to use opioids and other ineffective treatments. In fact, these pain clinics are among the biggest promiscuous prescribers, the top 10% of prescribers wrote half or more of the opioid prescriptions in all states.[31]

In this regard, Dr. Harris is absolutely correct that “physicians have not done enough” because they have not referred these patients to chiropractors and other CAM providers as the guidelines recommend.

As well as reducing the stigma against pain patients as the Task Force suggests, perhaps it should also recommend reducing the stigma against chiropractors that AMA and physicians have long perpetuated in its decades-long propaganda campaign to discredit the benefits of chiropractic treatments.

The Joint Commission

Undoubtedly the most shocking positive recommendation concerning the management of chronic pain and CAM providers was announced by the most politically-powerful medical organization in the nation but received no attention in the medical or mass media.

The Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations, sets the standards that must be met or else risk losing accreditation. The Joint Commission was established in 1951 to evaluate health care organizations and accredits more than 16,000 health care organizations in the United States, including 4,400 hospitals, more than 3,900 home care entities, and over 7,000 other health care organizations that provide behavioral health care, laboratory, ambulatory care, and long term care services. The Joint Commission also evaluates and accredits health plans and health care networks.[32]

The Joint Commission initially was a co-conspirator in the boycott of chiropractors from hospitals in 1962 but now fifty years later has reversed its policy to encourage the use of chiropractic as a nondrug solution in this battle against chronic pain.

In a revolutionary decree implemented as of January, 2015, the Joint Commission updated its evidence-based guideline on pain management, Clarification of the Pain Management Standard:[33]

 Rationale for PC.01.02.07 [New for ambulatory care and office-based surgery practice]

The identification and management of pain is an important component of patient-centered care. Patients can expect that their health care providers will involve them in their assessment and management of pain. Both pharmacologic and nonpharmacologic strategies have a role in the management of pain.

The following examples are not exhaustive, but strategies may include the following:

  • · Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy
  • · Pharmacologic strategies: nonopioid, opioid, and adjuvant analgesics.

Treatment strategies for pain may include pharmacologic and nonpharmacologic approaches. Strategies should reflect a patient-centered approach and consider the patient’s current presentation, the health care providers’ clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse.

One needs to understand the medical war against chiropractors to appreciate the irony of this new ruling by the Joint Commission. This is a complete reversal from its original position on chiropractors as trial evidence revealed at the Wilk v. AMA antitrust trial litigated by Mr. George McAndrews.

In 1962, the medical war against chiropractors was formerly announced by the AMA’s Committee on Quackery to “contain and eliminate the chiropractic profession.” The AMA used its influence to persuade the Joint Commission to make its “The Principles of Medical Ethics” a part of its Standards for accreditation of hospitals in order to ban chiropractors from hospital staffs.

Member hospitals and physicians were prohibited from all forms of exchange with chiropractors, most importantly, referring to or accepting referrals from medical doctors – a professional courtesy common among practitioners who referred to chiropractors seeking the best care for their patients.

Moreover, the punishment was severe: a hospital could be closed if it lost the Joint Commission’s accreditation. An individual physician could lose hospital privileges and be deemed unethical if found working with a chiropractor. A hospital itself could run the risk of losing accreditation if medical staff gave assistance or consulted with a chiropractor. Essentially chiropractors were branded taboo to physicians and hospitals alike.[34]

In this light, the Joint Commission’s new 2015 ruling on pain management that endorses chiropractic care is a 180 degree change in policy and speaks volumes about the importance to seek nondrug solutions to chronic pain and opioid painkiller abuse, even if it means recommending the once scorned chiropractors.

Hopefully as the American healthcare system implements “best practices” supported by evidence rather than politics/economics, the benefits of chiropractic as the most clinically and cost-effective treatment for the pandemic of chronic pain may finally have taken place. After all, it’s only taken 54 years and thousands of deaths and addictions for this revelation to be recognized by The Joint Commission.

White House FACT SHEET

President Barack Obama’s budget for 2017 will include $1.1 billion for fighting the opioid epidemic with a two-pronged effort that includes $920 million to help states to expand access to medication-assisted treatment for opioid use disorders, such as methadone and buprenorphine, commonly known as Suboxone. The long-term treatment is designed to lessen the craving for the opioids.[35]

Another $50 million in funding will go to expand substance abuse treatment programs and providers and $30 million to study the effectiveness of programs that use medication-assisted treatment under real-world conditions and find ways to improve them

However well-intentioned, it appears the White House initiative[36] is addressing the wrong end of the opioid equation. Bruprenorphene and methadone for replacement treatments and the overdose-reversal drug Naloxone certainly have their value for addicts on the verge of death, but there are nondrug solutions to chronic pain patients that are better, such as the world of chiropractic and other CAM treatments that were not mentioned by the White House report.

While expanding treatments after the fact and making more accessible medication-assisted treatment programs are needed, the real emphasis should be on the front end of this equation – prevention and alternatives to medications of any sort for the pandemic of chronic pain.

John Weeks, publisher and editor of the Integrator Blog News & Reports,[37] in his “Open Letter to President Obama”[38] published in the Huffington Post, also questioned the wisdom to use MDs to solve this opioid epidemic that they created:

“What needs questioning is whether you are empowering the right professionals to find the solutions. Do we have a full quiver of approaches, practices and practitioners at our service?

“Yet nowhere in your fact-sheet can one find the terms ‘non-pharmacologic’ or ‘integrative’. I fear you are putting this $1.1-billion in the hands of those whose myopic focus on Pharma fomented high levels of addiction in the first place. You are certainly aware of Albert Einstein's observation that ‘Problems cannot be solved with the same mind set that created them.’

“President Obama, your election broke a historic barrier for the color of people. Eight years later, you can break the harmful exclusion of these professionals and practices. Do the right thing for people in pain. Ensure that we can access all the strategies that can help resolve the opioid epidemic. Act affirmatively. Change the nation's therapeutic order in pain care.”

Good advice by Dr. Weeks that apparently has fallen on deaf ears and illustrates again that chiropractic care remains the elephant in the White House.

National Pain Strategy

In 2010, in response to a congressional mandate, the National Institutes of Health (NIH) contracted with the Institute of Medicine (IOM) to undertake a study and make recommendations “to increase the recognition of pain as a significant public health problem in the United States.” The Institute’s 2011 report called for a cultural transformation in pain prevention, care, education, and research and recommended development of “a comprehensive population health - level strategy” to address these issues.

           Here is an excerpt from the NPS report:

The Problem: The high prevalence of pain across the population and its impact on individuals and families creates a significant responsibility for health care professionals.

  • Despite the need to address this public health problem, many health professionals, especially physicians, are not adequately prepared and require greater knowledge and skills…
  • Education and training of health professionals…is insufficient, in part because educators lack access to valid information about pain and pain care.
  • As a result, practitioners may rely primarily on procedural or pharmacological approaches that alone are not effective and may have significant unintended adverse consequences such as addiction and medication misuse for which many health care providers lack skills and knowledge to identify and manage…
  • Change cultural attitudes about chronic pain, debunking stereotypes and myths related to people with chronic pain and various pain treatment options and emphasizing the value of pain self-management programs in enabling people to live better with chronic pain.

Although these bullet points by National Pain Strategy were spot on, there are other factors and omissions that were obvious to those of us already fighting in the battle against chronic pain. Chiropractic care was mentioned only in a tangential fashion; inexplicably the main focus remained on primary care providers as the portal of entry for chronic pain patients.

Problem with Pain Doctors

These efforts may be “too little, too late” considering the horses are already out of the barn and Big Pharma and the AMA have shown no intention to reign them in. Changing the status quo in American medicine by replacing MDs as the portal of entry for MSDs is an uphill battle with many foes supported by a great deal of money and misinformation.

Unlike the White House initiative, many of the other reports such as the NPS panel did remark on the inadequacy of MDs in chronic pain management:

“Physicians are not adequately prepared and require greater knowledge and skills…Education and training of health professionals…is insufficient…As a result, practitioners may rely primarily on procedural or pharmacological approaches that alone are not effective.”  

While this is a huge admission against the training of MDs, paradoxically the National Pain Strategy report also seemingly anoints the same inept and promiscuous primary care professionals who were the main architects of the current addiction crisis as the primary providers for chronic pain patients.

The NPS mentions in its report:  “While most pain care would be coordinated by primary care practitioners, specialists would be involved judiciously in the care of patients who have increased co-morbidities, complexity, or risk.[40]

The NPS recommendation to use MDs in the future as the primary contact for chronic pain patients turned a blind eye to the fact the same MDs were the very dealers of opioid painkillers that created this modern Cuckoo’s Nest in the first place! This is equivalent to turning the fire station over to the arsonists.

It may be appropriate to quote Albert Einstein: “Insanity is doing the same thing over and over again and expecting different results.”

Editor Mark Schoene also commented on the buffoonery proposed by the NPS to use MDs as the portal of entry for chronic pain patients considering they created this epidemic in the first place.

In his article, “Why Should the National Pain Strategy Be MD-Centric?” he comments on this quandary:

The draft report of the National Pain Strategy mentions the services of chiropractors and complementary/alternative providers—who play such a prominent role in the management of low back pain in the U.S. (They account for as many as 50% of back care visits.)

However, the report envisages a future where primary care physicians and pain specialists will play the most prominent roles in the prevention and management of chronic pain. Regarding low back pain, at least, this may not be a balanced and realistic view. It may exaggerate the capabilities of both primary care physicians and pain specialists—and downplay the potential contributions of other health professionals.

Primary care physicians and pain specialists don’t have unimpeachable backgrounds in the management of chronic pain in the U.S. These are the medical professions primarily responsible for the opioid overtreatment crisis. Are the two professions that helped create the worst pain management crisis in history of modern medicine capable of leading the way forward? That remains to be seen.[41]

Given their poor past performance and lack of education in this field, why the National Pain Strategy would depend primarily on these inept promiscuous prescribers is only explainable considering the 80+ consultants on the NPS panel did not include one chiropractor or CAM provider.

Unquestionably, the chiropractic profession remains the invisible factor in this equation. Chiropractors offer the best in nondrug care for the majority of MSDs, yet neither the NPS panelists nor the White House FACT SHEET mention the benefits chiropractors offer as the leading nondrug profession that deals with chronic pain. This oversight by the NPR and White House illustrates the depths of chirophobia among their panelists.

National Governors Association

Aside from the White House, the CDC, and the Institute of Medicine, and the other agencies who have responded to the new Cuckoo’s Nest of opioid poisoning in chronic pain care, our nation’s governors have also chirped in with recommendations since their state governments feel the brunt of this narcotic painkiller pandemic.

According to a news release by the National Governors Association (NGA), the purpose of its white paper is “to address the deadliest drug epidemic in U.S. history.” The Governors’ Priorities for Addressing the Nation’s Opioid Crisis provides recommendations for federal action to support states as they work to bolster education for health care providers, expand access to treatment for addiction and strengthen the public safety response.”

This report did admit, “We cannot end the opioid crisis without their leadership in changing the way we treat pain and addiction…over-prescribing of opioid painkillers has fueled the nation’s addiction crisis.”

Yet there was no blame placed on the promiscuous prescribers nor is there any mention of nondrug treatments as substitutes for opioid painkillers. The NGA report made many recommendations, such as the following:

  • more federal money to pay for  treatments,
  • adopting requirements for expanded education and training on pain management and safe opioid prescribing,
  • expediting the CDC’s guidelines for curbing dangerous prescribing practices and improving treatment for patients with chronic pain,
  • amend the Drug Addiction Treatment Act of 2000 to permit nurse practitioners and physician assistants to prescribe Bruprenorphene for opioid addiction,
  • develop additional guidance regarding best practices for addiction treatment and the distribution of Naloxone.

Once again the National Governors Association appears to be looking at the wrong end of this opioid equation speaking about how to make opioid agonists more available, such as Methadone, Bruprenorphene and Naloxone.

As the NPS and White House did, the NGA is looking for the medical professionals to stop the same epidemic of opioid painkiller abuse that they created. Once again, it appears the governors are putting the arsonists in charge of the fire station, perhaps hoping they will change their ways.

 “The heroin and opioid epidemic is an urgent public health and public safety crisis that affects people from all walks of life, taking tens of thousands of American lives each year,” said New Hampshire Gov. Maggie Hassan, vice chair of the committee. “Combating the heroin and opioid crisis is an all-hands-on-deck moment, and we must also partner with the private sector, from manufacturers to pharmacies and health care providers, to find solutions and change the way we treat pain in America.”[42]

If this is truly an “all-hands-on-deck moment” as Gov. Hassan suggests, this must be a mandate for chiropractors and other CAM providers to be fully embraced to offer nondrug solutions.

Of course, this stands in direct conflict with the promiscuous providers who are untrained in alternative pain management methods. Perhaps the most obvious solutions and change to the way we treat pain in America is to bypass the local MD and pain management “pill mills” altogether since they created this opioid addiction in the first place. Indeed, this opioid drug abuse begins in the MDs’ offices, not on the street.

On one hand, the NGA admits “Changing prescribing practices and our approach to pain management requires strengthening education and training for prescribers – not just physicians but nurses, physician assistants, dentists and veterinarians as well.” Once again, chiropractors are the proverbial “elephant in the Governors’ recommendations” as the leading nondrug pain practitioners.

As John Weeks and Mark Schoene both indicated, this MD-centric approach ignores there are numerous nondrug complementary and alternative providers who can intervene in this drug disaster, but are once again ignored by the NGA recommendations.

Of course, the most rational change to approach pain management is to use nondrug practitioners before opioids painkillers, epidural steroid injections and surgery. This is problematic considering MDs are uneducated in nondrug treatments as well as, due to their chirophobia, fail to refer these cases to chiropractors or CAM providers.

Dr. Erin Krebs at the AAPM annual meeting also mentioned in her talk “What the CDC's Opioid Prescribing Guidelines Mean for Primary Care Physicians,” [43]  the lack of access to nondrug treatments before the use of painkillers is a major problem:

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

The lack of access stems from two sources – one from MDs who rarely refer to chiropractors and from insurance payers who handcuff chiropractic benefits such as seen in workers’ compensation and many private programs where MDs limit chiropractic care instead of following the evidence-based guidelines such as the Clinical Practice Guideline: Chiropractic Care for Low Back Pain by Gary Globe, PhD, MBA, DC, et. al.[44]

Robert Lynch, DC, a member of the Maine Board of Chiropractic Examiners, testified to members of the Health and Human Services Committee concerning legislation to Prevent Opiate Abuse by Strengthening the Controlled Substances Prescription Monitoring Program:

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

Indeed, no other health profession would be given such slack.  Considering the harm from millions of opioid addictions and tens of thousands of deaths from overdose, “Do No Harm” seems to have been replaced with “Don’t Confuse Us with the Facts” as the new Hippocratic Oath.

Obviously this opioid painkiller epidemic is as much a cultural problem as it is a medical education/management problem. Changing the treatment paradigm will only occur when the medical professionals and Big Pharma support the guidelines to use nondrug care for chronic pain before the use of medications.

Such a huge change will not occur overnight and without great resistance by the AMA and Big Pharma, both of which already are on record opposing the CDC’s new guideline. Just as the Civil Rights Act did not stop Jim Crow’s discrimination, neither will Jim Crow, MD, embrace the way they treat chronic pain if it means taking money out of their pockets and swallowing their pride, admitting that those damn chiropractors were right all along!

However, it is the least they can do considering the AMA and Big Pharma created this mess in the first place. Their ability to thwart any responsibility and change in treatment illustrates Dr. NM Hadler’s comment, “The pen may be mightier than the sword, but it is not mightier than the dollar.”[45]

Simply put, the most obvious solution to this chronic pain problem is to address the front end of this pain management equation rather than dealing with the aftermath. Indeed, an ounce of prevention and nondrug treatments is worth a pound of painkillers.

This would require MDs to refer these cases immediately to DCs or other CAM providers rather than prescribing opioid painkillers and muscle relaxants as they typically do for chronic low back pain cases. Just as MDs must refer patients with dental problems to dentists instead of prescribing opioids, so too should MDs refer patients with MSD and back pain in particular to chiropractors.


 



[15] A Proactive Response to Prescription Opioid Abuse, Robert M. Califf, M.D., Janet Woodcock, M.D., and Stephen Ostroff, M.D. February 4, 2016 DOI: 10.1056/NEJMsr1601307

[20] Federal Register Notice: Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain

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

[23] Matthew Perrone Painkiller politics: Effort to curb prescribing under fire, Associated Press, Dec. 18, 2015

[24] Matthew Perrone Painkiller politics: Effort to curb prescribing under fire, Associated Press, Dec. 18, 2015

[25] Matthew Perrone Painkiller politics: Effort to curb prescribing under fire, Associated Press, Dec. 18, 2015

[26] Matthew Perrone Painkiller politics: Effort to curb prescribing under fire, Associated Press, Dec. 18, 2015

[27] http://www.painmed.org/annualmeeting/files/2016-annual-meeting-brochure.pdf

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

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

[30] Changing the Narrative: Amplifying Clinician Efforts to Curb Opioid Epidemic, Clinical Pain Advisor, February 19, 2016

[31] Leonard J. Paulozzi, MD, Gail K. Strickler, PhD, Peter W. Kreiner, PhD, Caitlin M. Koris, MPH, Controlled Substance Prescribing Patterns — Prescription Behavior Surveillance System, Eight States, 2013, Morbidity and Mortality Weekly Report (MMWR), October 16, 2015

[32] http://healthfinder.gov/FindServices/Organizations/Organization.aspx?code=HR1458

[34] George McAndrews closing argument, Wilk v. AMA, p. 69.

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

[42] Governors Make Recommendations To Address National Opioid Epidemic, National Governors Association meeting, February 18, 2016, http://www.nga.org/cms/home/news-room/news-releases/2016--news-releases/col2-content/governors-recommendations-opioid.html

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

[45] Hadler, NM, Stabbed in the Back; confronting back pain in an overtreated society, University of North Carolina Press, 2009, pp. 88


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