Editor’s note: This commentary is by James McDaniel, a chiropractor who is the immediate past president of the Vermont Chiropractic Association and the secretary for the Council on Chiropractic Guidelines and Practice Parameters.
The Centers for Disease Control and Prevention recently released their first ever Guideline for Prescribing Opioids for Chronic Pain. According to the CDC’s website, the guideline is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. The recommendations focus on the use of opioids in treating chronic pain — pain lasting longer than three months or past the time of normal tissue healing. The guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.
The statistics regarding the opioid epidemic are staggering. According to the CDC, about 40 Americans die each day from overdosing on prescription painkillers. As many as one in four people receiving long-term opioid therapy in a primary care setting struggle with addiction. The majority of prescriptions for chronic pain are for musculoskeletal back and neck pain. “The science of opioids for chronic pain is clear,” said CDC Director Tom Frieden, MD, MPH, in a news teleconference. “For the vast majority of patients, the known, serious and all too often fatal risks far outweigh the unproven and transient benefits, and there are safer alternatives.”
Unfortunately in Vermont, there are insurance policies in place that have the unintended consequence of essentially encouraging the prescription of opioids.
I was pleased to see that the first of the 12 CDC guideline recommendations states that opioids are not first-line therapy for chronic pain. Clinicians should first consider non-opioid pain relievers and/or non-pharmacological options. In my 25 years as a practicing chiropractic physician, I have witnessed firsthand how devastating and difficult some chronic pain can be to treat. There is no one size fits all approach for chronic pain. Frequently, multi-modal and multi-disciplinary therapies are required. The Vermont Chiropractic Association’s 2016 spring continuing education seminar was, very topically, on chronic pain. The speaker was a chiropractic physician who practices full time caring for our military service members at Walter Reed National Military Medical Center. This doctor articulated the important role that chiropractic physicians play as part of the team approach in treating the most difficult and complex cases of chronic pain at Walter Reed.
Unfortunately in Vermont, there are insurance policies in place that have the unintended consequence of essentially encouraging the prescription of opioids. According to the Vermont Medical Society Foundation’s 2012 White Paper, Safe and Effective Treatment of Chronic Pain in Vermont, “Current payment policies discourage: 1) use of evidence-based complementary and alternative medicine treatments; 2) team approach to caring for chronic pain patients; 3) case management; and 4) spending appropriate time with complex patients.” A telling quote from this white paper comes from a Vermont primary care provider. “One very big issue is how the insurance companies are actually driving a lot of the dependence on opioids. For example research shows that for chronic non-specific low back pain, chiropractic manipulation, acupuncture, and massage are all helpful. Yet many insurance companies won’t cover these. But they will cover the Percocet, which has not been proven to be helpful in research.”
In Vermont, insurance companies have classified chiropractic physicians under the category of “specialists.” Visits to specialists are subject to a significantly higher co-payment amount than visits to primary care providers. Removing chiropractic physicians from the specialist category and lowering the co-payment amount to that of a primary care visit will be a step in the right direction in reducing the existing financial disincentives that patients experience when seeking to use evidence-based chiropractic care for chronic back and neck pain.
