Opioid drugs and back pain - the chiropractic view

Opioid drugs and back pain - The chiropractic view

Melbourne, Vic, 1 February 2018 

Changes to the availability of codeine as an over the counter pharmacy product have reignited the debate on the value or otherwise of opiates for the treatment of back pain. A high proportion of opioid use in Australia is for spinal pain, especially low back pain. But misuse and overuse of these drugs and their serious side effects, including addiction, have forced the Federal government to take action. “Chiropractors have a strong role to play in this time of change” says the President of Chiropractic Australia, Professor Rod Bonello.

Calls to fight the opioid crisis have led to recent action being taken in Australia and elsewhere. From February 1st codeine is no longer be available from pharmacists without a prescription. Further, the Therapeutic Goods Administration (TGA) has proposed that in future GPs be banned from prescribing S8 opioids such as oxycodone and fentanyl. It has reported that prescription opioid overdoses, which include accidental overdose, are the highest they have ever been. The TGA advises that 2145 deaths in Australia were associated with oxycodone, morphine, codeine, fentanyl, tramadol and pethidine between 2011 and 2015. According to the United Nations, Australians used almost 20,000 daily doses of opioids per million population in 2016.1

The ban on over the counter sales of codeine will have an impact on pharmacies. Perhaps it is not coincidental that the Federal Health Minister, Craig Hunt, has approved a $20 million trial to take place in pharmacies where pharmacists will review patients on prescribed pain killers and write action plans for those who have chronic pain and may have self-management problems or drug-dependency. Every pharmacy in Australia will be eligible to access the funds, meaning patients will not have to pay for the service until the trial ends in 2020. That means that taxpayers are now funding pharmacists for a job which should not be required. The AMA has struck out against the Government with AMA President Dr Michael Gannon calling this move “another slap in the face for GPs”. He believes that this undermines the authority of the medical practitioner.

Where do chiropractors stand on this matter? Of course medications have their place in managing mechanical pain syndromes such as back pain. And of course as guidelines have long pointed out opioids should be a last resort medication for this purpose. The best evidence confirms that multimodal care is superior to medical care alone, but bickering over who is best to treat the patient and, worse still, who should be recommending which drug does not serve patients best interests. Asked to comment Professor Bonello said, “We have known for a long time that opioids have very limited use and are dangerous. It’s high time that their use and availability is being reviewed.”

It’s obviously time for Australians to rethink the use of drugs for back pain; they should only be used as last resort. First line must be employing the help of a team of health practitioners, including a chiropractor. 

It is the view of Chiropractic Australia that wherever possible quality evidence should guide clinical decision-making. Senior health policy researcher at the RAND Corporation Professor Coulter, writing in the Spine Journal this year published a systematic review and meta-analysis on the use of manipulation and mobilisation.2 His team found that the available evidence was of moderate quality and showed that both therapies are likely to reduce pain and improve function for patients with chronic low back pain. Further they confirmed that both treatments were relatively safe and may be promising additions to multimodal care programs.

In November last year a review of low back pain management undertaken by Sydney University reported that “an overwhelming amount of research showing most pain medicines have little to no effect compared to placebo for people with low back pain” and “Other effective options could include spinal manipulation, acupuncture, or multi-disciplinary rehabilitation programs”. 3

Twelve months prior to this, and partially as a response to the opioid crisis, the Canadian Chiropractic Association released a position statement “A Better Approach to Pain Management”.4 They called for increased availability of alternative treatments to opioids, especially conservative care strategies. Physical treatment solutions for mechanically based problems are inherently attractive. Chiropractic health commentator Marc Bronson has said “Chemical solutions for mechanical problems has failed. Going to see a GP for low back pain is like calling your plumber when you have electrical problems.” Chiropractic Australia believes that in complex pain cases relying on any one practitioner or a drug is unwise.

1. United Nations International Narcotics Control Board.
https://www.incb.org/…/Technica…/narcotic_drugs_reports.html

2. D. Coulter, C. Crawford, E. Hurwitz, H. Vernon, R. Khorsan, M. S. Booth, & P. M. Herman .
Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. The Spine Journal. Open Access DOI: http://dx.doi.org/10.1016/j.spinee.2018.01.013
3. A. Traeger, R. Buchbinder, I. Harris & C. Maher. Diagnosis and management of low-back pain in primary care. CMAJ November 13, 2017 189 (45) E1386-E1395; DOI: https://doi.org/10.1503/cmaj.170527
4. CCA. A Better Approach to Pain Management.
https://www.chiropractic.ca/…/A-Better-Approach-to-Pain-Man…
5. Photo credit: By Rotellam1 (Own work) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

If you would like more information about this topic, please contact Rod Bonello on 0402 907 515 or email rodneybonello@chiropracticaustralia.org.au
You can download this press release from:http://chiropracticaustralia.org.au/f…/press-media-releases/