Today we’re going to talk about getting off opioids. Even with the opioid crisis going crazy in our country, every single week, I have patients come in and they’ve been prescribed opioids as knee-jerk reactions right off the bat. We know that ain’t right! It’s time to start getting off opioids.
But first, here’s that bumper music
OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.
Before we get started, I want to ask you to go to chiropracticforward.com and sign up for our newsletter. It makes it easier to let you know when the newest episode goes live and it’s just nice of you.
We are honored to have you listening. Now, here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. Big goals. It’s a thing, folks… shoot big, and even if you fail, you’re still getting somewhere you weren’t going previously. It’s a win-win.
You have sashayed all fancy like into Episode #31
I spent the weekend last week in Longview, TX. Folks, I swear if you just looked out to check the weather, your face would fry right up like a pork rind. And pork rinds are gross so, if you’re down South, keep your face in the house. The sun is downright dumb right now, at this point in time. Certainly in the South.
Now, let’s turn our attention to drugs. Or getting patients off of them. Getting off opioids. This brings to mind an uncle of mine. He’s having some chronic pain. Granted, he’s very elderly but, he’s always been a healthy guy. Always. No seriously bad habits. Nothing like that.
The doctor said he was going to try taking him off of some of his 16 medications to see if that helped. Lol. Ya think so doc? Holy smokes and save the gravy. Sixteen medications. Imagine the obstacle courses of side effects with every single one of the sixteen medications he was taking? It boggles the mind. Hell yes, he’s sick. When does this mentality change?
We hope with podcasts like this, like evidence-based chiropractic groups on social media. There are people out there like us screaming and hollering to make it happen.
I had a young lady in my office just two weeks ago. Probably about 24 or 25 years old. She had fairly acute low back pain and had gone to the Urgent Care for it the day before. Guess what they did? Gabapentin was their first-line choice. First line.
No sir, no ma’am. That is NOT in keeping with every known current recommendation from the medical field. Here it is lined out for you.
Chiropractic, exercise/rehab, heat, and massage, maybe acupuncture if it’s a chronic issue. Throw in cognitive behavioral therapy and some other therapies I’m not all that familiar with to round it out. Some guides will say aspirin, ibuprofen, etc..
Second line would mostly be the anti-inflammatories like ibuprofen and aspirin. We covered a study some time back on the blog where ibuprofen was shown more effective than Tylenol but, other than that, do as you will.
Last line would be injections, more serious medications, and very last would be surgery. This is all about getting off of opioids.
That’s the order. You don’t skip everything and go right to Gabapentin. Not anymore anyway. The word isn’t percolating through the ether right now and getting to the physicians seeing this stuff on the front line. It’s all about getting off opioids, folks.
Here’s why. Let’s start with this one called “Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis” by Oliver Enke, et. al. and published in CMAJ(Enke O 2018). CMAJ stands for the Canadian Medical Association Journal so, it’s basically JAMA for Canadians. By making this clear to the listeners here, you know this isn’t chiropractors picking apart medical doctors and medicine. This comes from the authorities in the medical field.
Why They Did It
There’s scant evidence that an anti-convulsant like gabapentin is effective for low back pain yet the incidence of its use has gained significantly recently. The authors here wanted to find out if there was actually any effectiveness for the medication for low back pain.
How They Did It
- 5 databases were used to search for prior info and research on the matter.
- The outcomes were self-reported pain, disability, and adverse events
- Risk of bias was assessed and taken into account
- Quality of the info was assessed as well
- The info was gathered and numbers put on the information to make it make sense.
- 9 trials compared Topiramate, Gabapentin, or Pregabalin to placebo
- There were 859 participants
What They Found
- 14 out of 15 so…..93.3%….found anti-convulsants were not effective to reduce pain or disability in low back pain or lumbar radicular pain
- There was HIGH-QUALITY evidence of no effect vs. placebo for chronic low back pain in the short term.
- There was HIGH-QUALITY evidence of no effect for lumbar radicular pain in the immediate term
- The lack of effectiveness also comes with HIGH-QUALITY evidence of an increased risk of bad side effects.
Wrap It Up
The authors wrapped it up by saying, “There is moderate- to high-quality evidence that anticonvulsants are ineffective for treatment of low back pain or lumbar radicular pain. There is high-quality evidence that gabapentinoids have a higher risk for adverse events.”
So, we can close the door on gabapentinoids right? Time shall tell. How are we going to do our part to get the word to the right folks on this? Shoot me your suggestions. Count me in.
OK, we know now that gabapentinoids are foolish to prescribe for low back pain. What about opioids? If you’ve been listening very long to the Chiropractic Forward Podcast, then you likely already know the answer. But I like to add to the pile so here we do with a new one called “Changes in pain intensity following discontinuation of long-term opioid therapy for chronic non-cancer pain” by McPerson, et. al. and published in the Journal of the International Association for the Study of Pain. This paper was published on June 13 of 2018. (McPherson S 2018)
Why They Did It
The objective of this study was to characterize pain intensity following opioid discontinuation over 12 months.
How They Did it
- The paper was a retrospective VA administrative data study
- 551 patients were identified and included.
- They took data over a 24 month time period which included 12 months before discontinuation and 12 months after discontinuation.
- The Numeric Rating Scale for pain was used as an outcome assessment
Wrap It Up
“Pain intensity following discontinuation of LTOT does not, on average, worsen for patients and may slightly improve, particularly for patients with mild-to-moderate pain at the time of discontinuation. Clinicians should consider these findings when discussing risks of opioid therapy and potential benefits of opioid taper with patients.”
Well then, getting off of opioids should be easy. All of the info tells they do no good anyways right?
I had a new patient come in today. She’s 23. Last year, she had discectomies at three different levels. Can you imagine? Now, to be fair to the surgeon, she tried two months of physical therapy and was still unable to work or function in her daily life. She would intermittently go numb from the waist down. That’s big stuff but, should she have had surgery that quickly?
Does that mean she had cauda equina syndrome? Well….maybe. Numb from the waist down sort of sounds like it but did that include loss of bowel or bladder control? I’m not sure yet. I’m going to find out more about it as we treat. The surgeon may have been correct if it was indeed cauda equina and I’m not one to second-guess the guy right now going off of what I know right now.
The main point here is that she said she was on all kinds of meds the whole time and afterward and is still on gabapentin and trying to wean herself off of it. I went over the Canadian Medical Journal article we just went over at the start of this podcast and showed her how it’s doing nothing for her. She said she knows that. It doesn’t help her one bit but she has withdrawal issues if she takes less than a certain amount per day. These folks need our help and I hope I’m able to do my part for her.
We can avoid this stuff. I hate that I’m getting to her afterward though. I have to tell you. What if, on top of physical therapy (which I don’t see doing a ton of good for discs in my experience), what if on top of PT she would have been told to do massage, spinal manipulation, and I would argue spinal decompression and cold laser as well? Did she try an inversion table at all? What about Tai Chi, yoga, cognitive behavior therapy?
What I’m saying here is that PT is just part of the cocktail. The power is when PT is mixed with the rest. We are getting off opioids, folks.
I have shown you all paper after paper showing evidence-based proof of the effectiveness of chiropractic care but how about some cultural proof? Let’s do it!
What name is more respected by consumers in American than Consumer Reports? Honestly, I remember the name from when I was a kid. Consumer Reports is ingrained in the membrane, isn’t it? I say that it is so it must be so.
Here is an article from Consumer Reports from May 4, 2017(Carr T 2017). Just over a year ago.
The article talks about Thomas Sells, a veteran receiving alternative therapies through the VA. Along with chiropractic care, the article mentions alternatives for low back pain treatment like tai chi, yoga, massage, and physical therapy.
The article says, “Growing research shows that a combination of hands-on therapies and other nondrug measures can be just as effective as more traditional forms of back care, including drugs and surgery. And they’re much safer.”
That feels pretty nice, doesn’t it? Just a little “Awwww yeah…..”
They refer to the updated recommendations from the American College of Physicians that we have mentioned a million times here on the Chiropractic Forward Podcast. Even with only having had 31 episodes, we’ve probably mentioned it that many times.
They also mention a prior Consumer Report survey of 3,562 back pain sufferers where over 80% of them had tried yoga, tai chi, massage, or chiropractic and said it helped.
A big kudos to Consumer Report for also saying this, “But here’s the problem: People also told us that their insurers were far more likely to cover visits to doctors than those for non-drug treatments—and that they would have gone for more of that kind of treatment if it had been covered by their health insurance.”
Remember in the previous episodes where we have talked about the White House report that said clearly that CMS and health insurance policies in general “create barriers” to a patient seeking out effective, but an alternative, means of treatment? The link is in the show notes for your perusal.(2017)
Well, there you have it. Right there in Consumer Reports.
They also include a great quote from a woman in St. Charles, Illinois, “Spinal manipulation did me a world of good. My chiropractor had me do a lot of exercises on my own, which I continue to do. I’m so happy to get my active life back.”
We, chiropractors, see and hear this stuff all of the time but, the average Joe reading Consumer Reports or some other popular publication doesn’t usually.
This week, I want you to go forward with the knowledge that this profession is moving ahead. Not at a snail’s pace either. It’s moving fast right now. Paper after paper is coming out and 99% are in our favor.
Not only are we moving ahead, we’re moving ahead with help. Help from the big boys. Help from the White House to a certain extent, help from Congress to a certain extent (VA Bills), help from the medical profession to a certain extent, and help from your evidence-based colleagues like this podcast, the Forward Thinking Chiropractor podcast, the Evidence-based chiropractors facebook group, and other groups similar to them.
This stuff is happening. You can hold onto your ideas whatever they may be but I’m telling you, the door is cracked open and, if we are to bust that sucker down and shatter it into splinters, we will only do it through research and through an integration or merging of our profession with the thoughts and actions of other professions.
- We can get these folks off useless and harmful drugs and we can help keep more from becoming addicted. The process of getting off opioids has begun.
- You are educated at a level that you should never be intimidated or nervous to tell a GP that gabapentin is no longer a first-line treatment. Do it for yourself, do it for your patients, and do it for future patients. If not you, then who?
I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is a mechanical pain and responds better to mechanical treatment instead of chemical treatments.
When you look at the body of literature, it is clear: research and clinical experience show that, in about 80%-90% of headaches, neck, and back pain, patients get good to excellent results with Chiropractic when compared to usual medical care. It’s safe, less expensive, decreases chances of surgery and disability. Chiropractors do it conservatively and non-surgically with little time requirement or hassle for the patient. And, if the patient has a “preventative” mindset going forward, chiropractors can likely keep it that way while raising the general, overall level of health! At the end of the day, patients have the right to the best treatment that does the least harm and THAT’S Chiropractic, folks.
Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes. Feedback and constructive criticism is a blessing and we want to hear from you on a range of topics so bring it on folks!
If you love what you hear, be sure to check out www.chiropracticforward.com. We want to ask you to share us with your network and help us build this podcast into the #1 Chiropractic podcast in the world.
We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.
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(2017). The President’s Commission on Combating Drug Addiction and The Opioid Crisis.
Carr T. (2017). “The Better Way to Get Back Pain Relief: Growing research suggests that drugs and surgery may not be the answer for your bad back.” Consumer Report Retrieved May 4, 2017, from https://www.consumerreports.org/back-pain/the-better-way-to-get-back-pain-relief/.
Enke O (2018). “Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis.” CMAJ(190): E786-793.
McPherson S (2018). “Changes in Pain Intensity Following Discontinuation of Long-Term Opioid Therapy for Chronic Non-Cancer Pain.” PAIN.
Getting off opioids
Getting off opioids
Getting off opioids
Getting off opioids
Getting off opioids