The draft Guidance for Prescribing Opioids for Chronic Pain, issued in December 2015 by the U.S. Centers for Disease Control and Prevention, included “many complementary and alternative therapies (e.g., manipulation, massage, and acupuncture)” among its recommended non-pharmacologic approaches. However, when the final Guidance was released three months later, manipulative therapy and its 75,000 licensed chiropractic practitioners was not directly referenced. A recent study from James “Jim” Whedon, DC, MS, pictured, suggests that the CDC harmed its mission with its excision of explicit reference to manipulation. Patients using chiropractors were less likely to use prescription opioids.
Whedon is currently a researcher at the Southern California University of Health Sciences, and is co-chair of the Research Working Group of the Academic Collaborative for Integrative Health. He is a relatively rare resource in the integrative health community, as a specialist in diving into huge data sets of insurers and seeking to extract useful information. Whedon is a veteran of arguably the most important research center in this type of work, The Dartmouth Institute at the Geisel Medical School at Dartmouth College.
Whedon’s research began with awareness that “little is known about the comparative effectiveness of non-pharmacological care for low back pain as a strategy for reducing the use of opioid analgesics.” What is well known, as Whedon shared in his poster and presentation at the 2016 conference of the Academy of Integrative Health and Medicine, is that patients with such pain are swimming in opioid prescriptions. Whedon’s presentation included a Baskin-Robbins-like list of 39 opioid varieties. He postulated that opioid use would be less likely among those receiving chiropractic care.
In “Association between utilization of chiropractic services for low back pain and use of prescription opioids: Preliminary results of a health claims study,” Whedon reports what he found through examining the New Hampshire All Payer Claims Database. Of roughly 33,000 adults registered as having low back pain, slightly over a third saw a chiropractor. Of these, 38 percent had at least one opioid prescription. Of those who did not see a chiropractor, 61 percent had at least one opioid prescription.
The core question that interested Whedon was how many prescription fills the two sets of insured patients received. Those whose opioid prescription was integrated with chiropractic care had an average of 3.9 fills. Those who did not receive chiropractic manipulative therapy averaged 8.3 fills per patient. He estimated that the average per person opioid charges were $88 for those using chiropractors. The figure was $140, or 60 percent higher for those not using chiropractic care.
Whedon’s conclusions were, first, that the likelihood of filling a prescription for a high-risk drug of any type was 27 percent lower. Secondly, the likelihood of filling a prescription for an opioid analgesic was 57 percent lower in the chiropractic-using population.
“These are preliminary results,” Whedon cautioned. “We intend to analyze the data further, applying robust methods to reduce the risk of bias that can result from other differences between people who use chiropractic care and those who do not.”
Comment: While Whedon takes care to note that “no causal inferences can be made,” the associations should be of real interest to the CDC and other policy makers. A follow-up study might attempt to compare the whole costs of the chiropractic-using population and those who didn’t. These costs could include, on the one hand, the cost of chiropractic treatment, and on the other, the costs of other medications or treatment that may be prescribed for those on longer-term opioid treatment who may end up cycling into the addiction.