It’s difficult to know what word to apply to the use of opioid medications. Use, overuse or abuse. All can be applicable. The word “abuse,” however is the more commonly applied descriptor today. Opioid medications are available and are, seemingly, becoming stronger and more dangerous.
Here are some of the general statistics related to the “normal” (appropriately prescribed) use of opioid medications:
- 5% of patients given opioids will go on to long term use (i.e., >365 days). (Shah et al, 2017).
- One refill makes the patient 2.25 times more likely to go on to long term use. (Shah et al, 2017).
- Low back pain remains the leading indication for prescription opioid analgesics in clinical practice (Smith et al, 2017).
Quite honestly, the prospect of being prescribed an opioid medication strikes fear into my heart. It is profoundly effective but even more profoundly addictive.
Let’s consider for a moment my comment about opioids being effective. As mentioned above, low back pain is the leading indication for the prescription of opioid analgesics. What does the most recent literature say about this. “Treatment with opioids is NOT (my emphasis added) superior to treatment with non-opioid medications for improving pain-related function over 12 months” (Krebs, et al, 2018). Given this, what are the guidelines for physicians when you present to the clinic for spine related pain?
American College of Physicians Guidelines (Wegner, et al, 2017)
- For acute or sub acute low back pain (LBP; lasting <4 weeks or 4-12 weeks, respectively), superficial heat, massage, acupuncture, or spinal manipulation are recommended as first-line therapy.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants can be offered if patients request pharmacologic treatment for acute or sub acute LBP.
- For chronic LBP (lasting >12 weeks), a range of nonpharmacologic therapies should be used initially.
- If nonpharmacologic therapy is ineffective for chronic LBP, NSAIDs (first line) or tramadol or duloxetine (second line) should be considered.
- Clinicians should consider opioids only when the aforementioned treatments have failed and after consideration of their risks and benefits.
The first-line recommended therapy for spine related pain is Chiropractic care (i.e., spinal manipulation. Whedon, et al (2018) found that among adults with office visits for non-cancer low-back pain, the adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower for recipients of chiropractic care compared with non-recipients. Rhee, et al (2007) found that patients with low back pain who had chiropractic services for low back pain were 60% less likely to take narcotic drugs within 7 days after services compared to those without chiropractic services.
The use of conservative chiropractic management of pain issues is looking like an overall much safer means of caring for spine related pain issues.
Let’s look for a moment at other drug therapy options as outlined by the American College of Physicians. Early options to consider after the introduction of spinal manipulation include the use of non-steriodal anti-inflammatory drugs (NSAIDs). These drugs include: Tylenol, Advil, Motrin, Aleve, etc. The technical names are: acetaminophen, ibuprofen, naprosyn (naproxyn), etc.
First, let’s consider the warning label that is associated with this group of drugs. This includes both prescription and over the counter forms.
- The risk of heart attack or stroke can occur as early as the first weeks of using an NSAID. The risk may increase with longer use of the NSAID.
- The risk appears greater at higher doses.
- It was previously thought that all NSAIDs may have a similar risk. Newer information makes it less clear that the risk for heart attack or stroke is similar for all NSAIDs; however, this newer information is not sufficient for us to determine that the risk of any particular NSAID is definitely higher or lower than that of any other particular NSAID.
- NSAIDs can increase the risk of heart attack or stroke in patients with or without heart disease or risk factors for heart disease. A large number of studies support this finding, with varying estimates of how much the risk is increased, depending on the drugs and the doses studied.
- In general, patients with heart disease or risk factors for it have a greater likelihood of heart attack or stroke following NSAID use than patients without these risk factors because they have a higher risk at baseline.
- Patients treated with NSAIDs following a first heart attack were more likely to die in the first year after the heart attack compared to patients who were not treated with NSAIDs after their first heart attack.
- There is an increased risk of heart failure with NSAID use.
I think that it is obvious from the labeling instructions for the Food and Drug Administration of the US government that there are certainly issues related to the use of these medications as well. I’m fond of saying, “over the counter does not mean without side effects.”
Let’s look, in the form of further bullet points some of the issues related to NSAID’s:
- The use of NSAID’s is associated with extreme complications, including gastric ulcers, bleeding, myocardial infarction, stroke, and even death. The most current research indicates that the use of these medications can increase your risk of these events by 33%. Add to this the risk factors that you might already have – over weight, poor diet, high blood pressure, diabetes, the list goes on.
- “More than 70 million NSAID prescriptions are written each year, and 30 billion over-the-counter NSAID tablets are sold annually.” [Notice: 30 BILLION over-the-counter NSAID tablets are sold annually.]
- “5% to 10% of the adult US population and approximately 14% of the elderly routinely use NSAID’s for pain control.”
- Selling NSAID’s is a 9 billion dollar per year US industry.
- Prescription NSAID’s for rheumatoid and osteoarthritis, alone, conservatively cause 16,500 deaths per year.
- “NSAID’s are the most common cause of drug-related morbidity and mortality reported to the FDA and other regulatory agencies around the world.”
- Both natural and synthetic corticosteroids decreased healing capabilities, decreased the normal immune response, and have significant bone and gastric side effects.
What are the options to consider? We have already found that chiropractic care is an obvious and impressive source of care for all nature of spine and other musculoskeletal pain complaints. There is also the use of an often heard nutritional therapy – fish oil (EPA-DHA, or omega-3 fatty acids).
- One study looked at patients suffering chronic discogenic pain (neck and low back) (Maroon, 2006). After seventy-five days on fish oil, 59% of patients were able to discontinue their prescription NSAID’s, 60% indicated that their overall pain improved, 80% stated that they were very satisfied with the improvement, and 88% stated they were satisfied with their improvement and that they would continue to take the fish oil.
- In this study, fish oil supplementation was not associated with any significant side effects.
- “Omega-3 EFA fish oil supplements appear to be a safer alternative to NSAID’s for treatment of nonsurgical neck or back pain.”
- “The agent best documented by hundreds of references in the literature for its anti-inflammatory effects is omega-3 EFA’s found in fish and in pharmaceutical-grade fish oil supplements.”
- The beneficial anti-inflammatory effects of high-dose fish oil include the reduction of joint pain from rheumatoid and osteoarthritis, improvement in dry eyes and macular degeneration, reduced plaque formation, reduced arrhythmias, and reduced infarction from coronary arthrosclerosis.
Where do these precautions and recommendations leave us? I think that the recommendations of the American College of Physicians is sound.
- For acute, subacute and chronic pain suffers the best starting point is the use of manipulative therapies from a Chiropractor. It is profoundly safe and incredibly effective. When coupled with ancillary procedures to address soft tissue involvement an incredibly fast rate of recovery can be observed. These simply therapies tend to see recovery in 98+% of our presenting cases.
- There are instances where we find concurrent care with your primary care provider may be of benefit. There are occasional cases that are more stubborn so we introduce the use of NSAID's and perhaps a "muscle relaxant" into the therapy regime. These more difficult cases do benefit from the concurrent care from the Chiropractor, but when supplemented with NSAIDs/muscle relaxants we see 99+% recovery.
- There are some instances more invasive therapy is needed. These "invasive" therapies include stronger drug therapies (opioids) and potentially surgical interventions. I am delighted to report that these instances are a substantial minority of presenting cases.
If you are having pain issues that you feel are in need of some form of care, we strongly urge you to consider seeing a chiropractor. When seeking out a chiropractor you need to find the physician that will take a thorough history, do a complete and detailed examination and take the time to discuss the findings and recommendations so you fully understand the issues. The care recommendations should be reasonable and make sense.