Non-Opioid More Effective While Chiropractic Maintenance May Be The Most Effective

This Chiropractic Forward podcast this week is a bit of a mishmash of a couple studies that will ultimately intertwine into a valid discussion including chiropractic maintenance and a discussion about non-opioid vs. opioids.

Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast where we talk about issues related to health, chiropractic, evidence, chiropractic advocacy, and research. Thank you for taking time out of your day I know your time is valuable and I want to fill it with value so here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall.

Before we get started, I want to draw your attention our website at Just below the area where you can listen to the latest episode, you’ll see an area where you can sign up for our newsletter. I’d like to encourage you to sign up. It’s just an email about once a week to let you know when the episode is updated and what it’s about. Also, if something brand new pops up, we’ll be able to tell you about it quickly and easily.

You have moonwalked into episode #19. I hope you have enjoyed the previous episodes. Particularly the last six which were a part of a series all debunking the “Chiropractors Cause Strokes” myth and then another series of podcasts reviewing the lancet articles on low back pain. The Chiropractic profession NEEDS you to share those 6 episodes in particular

Now, since we have covered the impact of the opioid crisis exhaustively, I will cover it only briefly for reference purposes.

  • Low back pain is the single leading cause of disability worldwide.
  • 8 out of every ten people will experience back pain. I will admit that I have never met anyone in 45 years of life on this Earth that fits into the 20% that apparently never suffers from any low back pain.
  • Back pain is the second most common reason for visits to the doctor’s office right behind upper-respiratory infections.
  • With such gains and leaps in the medical industry as far as treatment goes, low back pain is stubbornly on the rise.
  • More than half of Americans who experience low back pain spend the majority of the work day sitting. 54% to be exact. Did you know that an equal number of patients first seek help with a chiropractor as seek help with a medical practitioner for back pain?
  • Back pain in general costs $100 billion dollars every year when you factor in lost wages and productivity, as well as legal and insurance overheads.

Should there be any doubting the necessity of non-pharmacologic treatments for low back pain at this point, then a person is simply beyond help. We can only refer you to a report from the Executive Office of the President of the United States’ report titled “The Underestimated Cost of the Opioid Crisis” put forth by the Council of Economic Advisers in November of 2017[1].

That reminds me, that paper citation as well as any others we talk about here will be in the show notes so always check out www.chiropracticforward.comfor those show notes.

The report paints a fairly complete picture of this national crisis. The medical field helped create the national crisis. Now, will they help put the fire out? It seems the answer to that question is, “Yes!”

Now that the nation and the medical field understand the danger of opioids, we are certainly starting to see an increase in research having to do with opioids. A brand new paper of particular note was published March 6, 2018 in JAMA, performed by Dr. Erin Krebs, MD, et. al. and is titled “Effect of Opioid vs. Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain. The SPACE Randomized Clinical Trial [2].”

Why They Did It

How They Did It

  • 240 subjects
  • 12-month trial
  • Randomized with masked outcome assessments
  • Test subjects experienced moderate to severe chronic back, hip, or knee osteoarthritis pain despite analgesic use.
  • Interventions tested were opioids and nonopioids
  • The first step of the opioid group included immediate-release morphine, oxycodone, or hydrocodone/acetaminophen
  • The nonopioid group’s first step was acetaminophen or a nonsteroidal anti-inflammatory drug.
  • Medication was changed and/or adjusted within each group according to patient response.
  • The main outcome assessment used was Brief Pain Inventory (BPI) scale.

What They Found

  • 240 subjects completed the trial
  • There was little difference between the two groups in terms of function over the course of the 12 months of testing.
  • Pain intensity was actually much more improved (statistically significant) in the NONopioid group.
  • Adverse harms (bad side-effects) were significantly greater in the opioid group.

Wrap It Up

Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”

Again, I don’t wish to belabor a point we have covered several times but, for the purpose of this discussion, we must mention them. The medical field is stepping up to the challenge slowly but, I would argue significantly. The American College of Physiciansupdated their treatment recommendations for chronic and acute low back pain just last year. In the report[3]they recommended spinal manipulation prior to taking ibuprofen or other over-the-counter NSAIDs for low back pain. One month later, in JAMA (the journal for the American Medical Association) there was a paper demonstrating the effectiveness of spinal manipulative therapy[4]. IN JAMA!! The significance of this cannot be overstated.

Next, let us talk a little bit about chiropractic treatment for low back pain, what it looks like, and whether chiropractic maintenance care really makes any sense. that recommend preventative (AKA Wellness Care) to their patient bases.

Let me start by stating my opinion and the opinion of most evidence-based chiropractors I would assume: active, complaint-focused treatment should have a start and it should have an end. Plain and simple, cut and dry. How does chiropractic maintenance fit in there?

If a patient is coming in for a complaint such as neck pain, the practitioner should decide whether the pain is acute, subacute, or chronic and, based on history and exam findings, be able to give some good, responsible recommendations for the treatment of the complaint. Typically, the acute schedule will be shorter in terms of treatments and time vs. a chronic condition. A chronic condition is more difficult to treat and one would reasonably expect the schedule for a chronic condition to be longer and more intense. The CCGPP guides[5]can be useful for this sort of decision-making.

For example, Medicare has broken down how they value diagnosis codes into groups A-D. In their system, the secondary diagnosis codes can be the difference between seeing a patient only 12 times or as much as 30 visits for a specific complaint. A simple low back pain diagnosis or muscle spasm diagnosis garners 12 visits from Medicare while degeneration of lumbar intervertebral disk or lumbar spinal stenosis will indicate up to 30 visits for treatment.

In the personal injury world, according to the Quebec Taskforce on Whiplash Associated Disorders, if a patient is assessed with a Grade III whiplash, assuming complications, they can be treated up to 76 visits over 56 weeks. That’s a lot of treatment but the length of treatment reflects the severity of injury as a Grade III whiplash is associated with ligament tearing and/or neurological findings.

For more information on general guides for practice protocol, please reference a previous blog of ours on the topic at listen to our podcast at The guides can be found in Episode #5 which can be found at this link:

What does all of that have to do with chiropractic maintenance care? The point being made is that there are a lot of different chiropractors. Seventy thousand plus in America alone and, although there are guidelines out there, chiropractors do not typically seem to have a general overall desire to implement them. One chiropractor may tell you that they will need to see a chronic neck pain patient 50 visits a year to clear it up while another may see the same condition for 18-20 visits. This is not only frustrating for chiropractors, it’s highly frustrating for patients as well.

Of course, this is not true but, don’t chiropractors commonly recommend preventative or chiropractic maintenance care that may resemble “rest of your life” care? It’s my opinion that once a complaint resolves, patients should see their chiropractor once a month. Minimally, they should be seen once every two months. That is chiropractic maintenance and that is my opinion. I will find more than a handful of chiropractors that will disagree with me on both ends of the spectrum but the key to the idea is “chiropractic maintenance” care in some sort of ongoing fashion.

There is research for chiropractic maintenance care. Take this paper from 2011 for example. It is by MK Senna, it’s titled “Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?” and was published in the prestigious Spine journal[6]. For the purpose of this study, keep in mind that SMT stands for spinal manipulation therapy. Also of special note is that chiropractors perform over 90% of SMTs in America so I commonly interchange SMT or spinal manipulation therapy with the term “Chiropractic Adjustment.”

Why They Did It

The authors of this paper wanted to check how effective spinal manipulation, also known as chiropractic adjustments, would be for chronic nonspecific low back pain and if chiropractic maintenance adjustments were effective over the long-term in regards to pain levels and disability levels after the initial phase of treatment ended.

How They Did It

  • 60 patients having chronic low back pain of at least six months duration
  • Randomized into three different groups:
  • 12 treatments of fake treatment for one month
  • 12 treatments of chiropractic adjustments for a month only
  • 12 treatments for a month with maintenance adjustments added every 2 weeks for the following 9 months.
  • Outcome assessments measured for pain and disability, generic health status, and back-specific patient satisfaction at the beginning of treatment,

What They Found

  • Patients in groups 2 and 3 had significant reduction in pain and disability scores.
  • ONLY group 3, the group that had chiropractic maintenance adjustments added, had more reduction in pain and disability scores at the ten-month time interval.
  • The groups not having maintenance adjustments, pain and disability scores returned close to the levels experienced prior to treatment.

Wrap It Up

The authors conclusion is quoted as saying, “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.”

For my own wrap up this week I would say simply this:

  • Low back pain is a significant issue for Americans
  • It is one of the biggest reasons people get hooked on opioids
  • As shown above, opioids are no more effective than non-opioids so why would anyone use them?
  • Chiropractic has been shown superior to nonopioids (specifically Diclofenac[7])
  • The big boys of the medical field (ACP and AMA) and the White House itself are recommending chiropractic for the treatment of low back pain before using even NSAIDs

So, why is this even in the discussion phase rather than the implementation phase? Why are we not inundated with low back pain patients at this very minute?

We have to go back to a different White House report that came out recently discussing the fact on page 57 of the report that although chiropractic has been proven effective, barriers to chiropractic treatment have been put in place by CMS and health insurance providers[8].

The specific wording is as follows: “A key contributor to the opioid epidemic has been the excess prescribing of opioids for common pain complaints and for postsurgical pain. Although in some conditions, behavioral programs, acupuncture, chiropractic, surgery, as well as FDA-approved multimodal pain strategies have been proven to reduce the use of opioids, while providing effective pain management, current CMS reimbursement policies, as well as health insurance providers and other payers, create barriers to the adoption of these strategies.” “The Commission recommends CMS review and modify rate-setting policies that discourage the use of non-opioid treatments for pain, such as certain bundled payments that make alternative treatment options cost prohibitive for hospitals and doctors, particularly those options for treating immediate post-surgical pain.”

It’s all there. It’s simple. All we can do is continue to tell everyone and beg for your help in telling everyone as well.

It is up to us to spread the good news and all it takes is hitting the Share button on social media. Retweet, help get the word out.

I challenge you to tell your people. It’s so easy but it takes a little initiative on your part. You actually have to do something now. Your profession is poised on the edge of stepping into a role it is uniquely able to fulfill and excel in but NOT unless we reach out and take that role and hold onto it.

Our effectiveness is proven. It’s time. Help us help you. I’m not asking for donations. I don’t want your money. I want your influence. So do us a favor if you will and share this information and, if it didn’t get the response you hoped for, share it again. Print out the parts of this article you find particularly effective and send it to medical practices in your area.

Make a difference.

Did you know that research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, in comparison to the traditional medical model, patients get good or excellent results with Chiropractic? Chiropractic care is safe, more cost-effective, it decreases your chances of having surgery, and it reduces your chances of becoming disabled. We do this conservatively and non-surgically. In addition, we can do it with minimal time requirements and minimal hassle on the part of the patient. And, if the patient develops a “chiropractic maintenance” mindset going forward from initial recovery, we can likely keep it that way while raising the general, overall level of health! And patients have the right to the best treatment that does the least harm. THAT’S Chiropractic folks.

Please feel free to send us an email at dr dot williams at and let us know what you think or what suggestions you may have for us for future episodes.

If you love what you hear, be sure to check out As this podcast builds, so will the website with more content, products, and chances to learn.

We cannot wait to connect again with you next week. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

Source Material

  1. The Council of Economic Advisers, The Underestimated Cost of the Opioid Crisis. 2017: The Executive Office of the President of the United States of America.
  2. Krebs E, Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain – The SPACE Randomized Clinical Trial.JAMA, 2018. 319(9): p. 872-882.
  1. Qaseem A, Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.Ann Intern Med, 2017. 4(166): p. 514-530.
  2. Page N, Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain.Journal of American Medical Association (JAMA), 2107. 317(14): p. 1451-1460.
  3. Baker G, Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain.Topics in Integrative Health Care, 2012. 3(4).
  4. Senna MK, Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?Spine (Phila Pa 1976), 2011. Aug 15; 36(18): p. 1427-37.
  5. Wolfgang J, e.a., Spinal HVLA-Manipulation in Acute Nonspecific LBP: A Double Blinded Randomized Controlled Trial in Comparison With Diclofenac and Placebo.Spine, 2012. 38(7).
  6. The President’s Commission on Combating Drug Addiction and The Opioid Crisis. 2017.


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