THE ELEPHANT AT THE SUMMIT
The 2019 National Rx Drug Abuse and Heroin Summit held in Atlanta was a major gathering of stakeholders, noted speakers and 3,000 attendees to discuss the huge opioid problem. The leaders of the NIH, CDC, the National Institute on Drug Abuse, and President Trump were among presenters.
According to the National Institute on Drug Abuse:
The Rx Drug Abuse & Heroin Summit is the largest national collaboration of professionals from local, state, and federal agencies, business, academia, treatment providers, and allied communities impacted by prescription drug abuse and heroin use. It is the event for decision makers and allied professionals working to address this public health emergency.
The Rx Drug Abuse & Heroin Summit is the largest collaboration of professionals and advocates who have been impacted by Rx opioid abuse/diversion and heroin use.
Attendees should include: Counselors, social workers, therapists, psychologists, and interventionists; physicians, psychiatrists, nurses, pharmacists, and dentists; advocates, families, and people in recovery; law enforcement personnel; public health and prevention officials; federal, state, and local officials, and lawmakers; education specialists and researchers; treatment center owners and operators; attorneys; first responders; and business leaders.
However, take note chiropractors were excluded from this list of attendees. Indeed, what was not mentioned at this Summit may prove to be more important than new drug interventions or legal/social/political efforts to stem the flow of these narcotic painkillers. It appears this may be an example of Occam’s razor where the simplest answer to a problem was overlooked by myopic medical eyes too prejudiced to see clearly the benefits of chiropractic care.
As a 40-year practicing chiropractor, I was dumbfounded to learn my profession was not included in this conference. The snub of chiropractic from the Summit was shocking considering today evidence-based medical guidelines adopted by every professional association and government health agency rank chiropractic care among the leading nondrug treatments for low back pain that currently constitutes ~30% of prescription opioids; all musculoskeletal disorders amendable to chiropractic care amount to over 70%.
Here is a short list of the recent research studies supporting the new appreciation of chiropractors published by the American College of Physicians, Journal of the AMA, National Pain Strategy, Centers for Disease Control and Prevention, and The Lancet series on low back pain have substantiated the current evidence-based medical treatment guidelines promoting conservative and alternative treatments for LBP now utilized in the Official Disability Guidelines (ODG), MDGuidelines, and the American College of Occupational and Environmental Medicine (ACOEM).
Mark Schoene, editor of the Back Letter, an international scientific spine journal, commented on the buffoonery to use MDs as experts for chronic pain patients considering they created this terrible opioid epidemic in the first place. He commented on this quandary in his article, “Why Should the National Pain Strategy Be MD-Centric?”
“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 the history of modern medicine capable of leading the way forward? That remains to be seen.”
“Chirophobia” at the Summit
Inexplicably none of the recent research showing the benefits of complementary and alternative medicine (CAM) rendered by chiropractors was presented at the Summit. This is a major omission that speaks volumes of the prevailing bias resonating among medical providers. Obviously, someone at Healthcare Made Practical did not do his homework to omit this valuable nondrug solution to the majority of chronic pain problems.
One must question why the Summit organizers would host an event excluding the 3rd largest physician-level health profession in the nation and the acknowledged leader in conservative (nondrug, nonsurgical) care for the epidemic of back pain.
Apparently chiropractic is the proverbial elephant at the Summit that no one wanted to discuss although it looms large in every evidence-based guideline.
For example, there were 164 events/classes on the schedule, but not one event presented the proven benefits offered by the chiropractic profession to reduce opioid consumption. There were 320 speakers listed, but not one was a chiropractor nor did the agenda feature anyone speaking of CAM treatments despite the numerous supportive research studies and public popularity.
Nor was there a class on the paradigm shift in spine care showing the research trends away from usual medical care (drugs, shots, surgery) to “nonpharmacologic” conservative care as every guideline now recommends.
Not one class at the Summit showed the evidence-based guidelines for back pain that now list chiropractic care as a front-line treatment. This is a huge academic oversight, a disservice to the attendees, and a malpractice issue to opioid victims who might prefer a nondrug solution to their chronic pain if they were given their right to access alternatives as the Informed state and federal Consent laws demand.
Indeed, a class on the paradigm shift to chiropractic care to lower opioid prescriptions would have been among the most impactful presentations in the entire Summit. Numerous studies have found the implementation of chiropractic care has greatly reduced the use of opioid painkillers:
- 2016: Chiropractic Care Reduces Opioid Use indicated a 57% reduction in opioid use when chiropractic care was utilized in treatment.
- 2016: Cross-Sectional Analysis Of Per Capita Supply Of Doctors Of Chiropractic And Opioid Use In Younger Medicare Beneficiaries found a higher supply of DCs reduces the number of opioid prescriptions.
- 2017: Complementary and Alternative Medicine in the Military Health System found at MTFs where chiropractic is offered, 59% reported a reduction in narcotic painkillers use
- 2018: Treatment of Low Back Pain With Opioids and Nonpharmacologic Treatment Modalities for Army Veterans In the Veterans Health Administration (VHA) there is growing interest in the use of nonpharmacologic treatment (NPT) for low back pain (LBP) as pain intensity and interference do not decrease with opioid use.
- 2011:Does Maintained Spinal Manipulation Therapy For Chronic Nonspecific Low Back Pain Result In Better Long-Term Outcome?
SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.
- 2004:Efficacy Of Preventive Spinal Manipulation For Chronic Low-Back Pain And Related Disabilities: A Preliminary Study.
Intensive spinal manipulation is effective for the treatment of chronic low back pain. This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective post-intensive treatment disability levels. Future studies, however, are needed to confirm the finding in a larger group of patients with chronic low-back pain.
THE SUMMIT IS RIGGED
If President Trump had known of this exclusion of chiropractic, he might have said, “This Summit is rigged.”
Not only are he and his family reportedly chiropractic patients, in 2017 the President’s Commission on Combating Drug Addiction and the Opioid Crisis headed by Gov. Chris Christy specifically mentioned chiropractic care was “proven to reduce the use of opioids.” 
Recently the present Surgeon General of the US, Jefferson Carter, MD, MPH, recommended using nondrug conservative care by chiropractors before prescribing narcotics for patients with back-pain.
As Anthony Rosner, PhD, said in his testimony before The Institute of Medicine:
“Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”
It’s a shame the 3,000 attendees at this Summit weren’t informed of this good news about chiropractic care.
Overlooking a proven nondrug solution to chronic pain is either due to poor research methodology, medical bias that refuses to acknowledge the evidence-based research of a competitor, or political gerrymandering by the medical-industrial complex that continues to thwart the implementation of nondrug therapies. Whichever, many patients will continue to suffer as long as they are denied access to conservative care.
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. Inexplicably Dr. Krebs was not asked to speak at the Summit despite her national reputation and research promoting CAM for chronic pain.
She 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.”
Dr. Krebs also mentioned the lack of nondrug treatments such as chiropractic spinal manipulation:
“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.”
She hit the nail on the head of this opioid pandemic — the lack of access to optimal non-opioid pain care consisting of low tech, high touch treatments such as chiropractic care and massage therapy for the ‘nonspecific’ cases of mechanical origin.
Studies from Johns Hopkins University have documented making alternative treatments more available reduces opioid use. James Heyward, MPH, a research analyst at the Johns Hopkins Center for Drug Safety and Effectiveness mentioned:
“Expanding the availability of alternative therapies for chronic pain, including low back pain, is absolutely key to addressing the opioid crisis.
“Millions of Americans experience chronic pain each year and we can’t focus solely on restricting access to opioids without simultaneously making alternatives for treating chronic pain more widely available. Opioid prescribing will go down if patients are offered a broader array of alternative treatments for their pain.”
BTW: Mr. Heyward also did not speak at the Summit. It appears the Summit while well-intentioned had no interest to think out of the medical box with innovative CAM ideas nor did the administrators seek Occam’s Razor to cut through the plethora of failed pharmaceutical treatments.
According to investigative journalist and editor Mark Schoene of the BACK Letter, it’s painfully obvious “back care in the United States has been heavily oriented around opioids, excessive imaging, and early referrals to surgeons. There has been broad overuse of numerous, heavily marketed back pain treatments, from passive physical modalities to invasive pain interventions such as laser and open-spine fusion surgery,” a lucrative enticement that averages an estimated $77,500 at the Mayo Clinic, despite critics stating fusion surgery has been abused, often unnecessary, ineffective, and disabling.
So, in this area of medicine, patients would be well advised to take their doctors’ diagnostic and treatment recommendations with a large grain of salt,” according to Mr. Schoene who wrote about the inaccurate and aggressive marketing in ‘Massive Wave of Unregulated Medical Marketing Putting Patients and Providers in Peril’:
Regulators have not caught up with this tidal wave of marketing. And much of the information that goes out to physicians and patients in these marketing efforts is unregulated—and of questionable accuracy…
Anyone familiar with the history of the spine field knows that there have been a series of controversies and scandals over the past few decades, in which inaccurate information and aggressive marketing have played major roles.
Some of these scandals and controversies include the Vioxx debacle, the overuse of the bone grafting agent INFUSE (BMP-2), the excessive utilization of spinal fusion for “discogenic” pain and other unvalidated indications—and the promotion of stem cell therapy for disc degeneration, to name a few.
I might add the most pervasive example of scandal and aggressive marketing was the Laser Spine Institute that promoted the “bad disk” diagnosis as a sole criterion for surgery when, in fact, it is well established that “bad disks” appear in pain-free people. LSI closed its doors on March 1, 2019, unable to pay numerous lawsuits, but it had misled millions of people with “widespread misconceptions” about the need for spine surgery.
The public will remain easily fooled if they have the mistaken belief back pain is mainly due to a “bad disk” that necessitates back surgery. Indeed, follow the money, follow the lies, and the “bad disk” lie is among the largest of all told by the medical-industrial complex keeping it alive.
THE GOAL UNMET
The stated goal of the Summit was:
The Rx Drug Abuse & Heroin Summit is where solutions are formulated, stakeholders from Federal to family convene, and change begins. It is the annual gathering for stakeholders to discuss what’s working in prevention and treatment.
Considering the omission of chiropractic and CAM solutions despite the proven effectiveness, one must ask if anything truly significant came from the Summit. One thing is for certain: chiropractic care remains the proverbial elephant in the room at the Summit.
 Denise Boudreau, PhD, Michael Von Korff, ScD, Carolyn M. Rutter, PhD, Kathleen Saunders, G. Thomas Ray, Mark D. Sullivan, MD, PhD, Cynthia Campbell, PhD, Joseph O. Merrill, MD, MPH, Michael J. Silverberg, PhD, MPH, Caleb Banta-Green, and Constance Weisner, DrPH, MSW. “Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain,” Pharmacoepidemiol Drug Saf. 2009 December; 18(12): 1166–1175. doi:10.1002/pds.1833.
 The President’s Commission on Combating Drug Addiction and the Opioid Crisis, 2017, pp. 50
 Surgeon General’s Advisory on Conservative Care: What If?
https://www.dynamicchiropractic.com/mpacms/dc/article.php?id=58383, April 1, 2019
 The Institute of Medicine: Committee on Use of CAM by the American Public, Testimony for Meeting, Feb. 27, 2003
 “What the CDC’s Opioid Prescribing Guidelines Mean for Primary Care Physicians,” Clinical Pain Advisor, February 19, 2016
 Heyward J, Jones CM, Compton WM, et al. Coverage of nonpharmacologic treatments for low back pain among US public and private insurers. JAMA Network Open, 2018;1(6):e183044. doi:10.1001/