336- Updated Medication Guidelines for Low Back Pain

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. This week we are back with the research and we are going to take a look at a brand new study. We're talking 2022 and this is titled Systematic Review of Guideline Recommended medications prescribed for the treatment of Low Back Pain. Lot of great clinical pearls in this one, so please stay tuned. Before we get started, I want to say a few words about the smart chiropractor and the smart chiropractor can power your patient journey to provide you with more new patients, better retention and more consistent reactivations without spending any money on advertising. You can check it all out at the Smart chiropractor. Com. We're talking email automation, social automation in office patient education and really great monthly campaigns, weekly topics and daily posts so you can teach and invite your audience consistently. Again, you can check it all out atthe smart chiropractor.com but on today's podcast, we're talking research again. This came out in Chiropractic and manual therapies in 2022. So it is hot off the presses and it was taking a look at over 300 citations, 50 full text articles and basically systematic review of guideline recommended medications prescribed for the treatment of low back pain. What's going on in the medication space? What does the research say and what are the guidelines telling us? I think at this point it's super, super clear that in almost all cases there's always an exception. Medications are just not the way to go. Surgery should be performed probably at a tenth of a clip that it currently is. That's a story for another day. However, let's take a look and see what the research says. So this is not comparative to conservative care, it's just comparative to other medications. So why is this a big deal? Well, 68% of physician visits in the United States involve drug therapy. And the most frequently prescribed therapeutic classes include analgesics. So nearly 70% of physician visits involve drug therapy. You can take that with what you will. There's probably a lot of one liners we can get out of that, but that's the reality of what's happening. And one of the most common classes are analgesics. It's, it's been estimated about 30% if you take a primary Care physician office, for instance, about 30% of their daily volume is related to spine and neuromusculoskeletal care. So no big surprise that so many visits result in medications and quite frankly in many cases. I heard my in laws talking about this not too long ago. You know, getting text reminders, getting email reminders about coming in to see the primary care so a prescription could be refilled. That's what happens a lot of time, a lot of times it's just come in for your six month, come in for your yearly. So I can rewrite the script and ask you a few quick questions. Now in many cases that is warranted and a great thing if you're reliant upon medications to live. But it's a slippery slope, especially when we start talking about analgesics, pain relievers and things like that. And just the complete guideline discordance between what is recommended and what's actually happening in so many of these providers offices. So just an important little context there to set. So each year if this, these numbers are going to, you know, if you're sitting down, I hope you are sitting down. Each year over 860 million drugs are prescribed in the United States. And 4 trillion doses of medication are prescribed each year across the world. That's a lot. Between 2015 and 2018 and 30 day windows, nearly half of every adult in the United States used at least one prescription. Let me say that again. Couple year period, couple years ago, in any 30 day period, 50% of people in this country, the United States, which where it's being recorded right now, were using at least one prescription. Over 25% in the US and the UK were reported taking three or more medications. And over 10% of US adults had five or more medications each and every day. Absolutely wild to me. But that's the way it is, that's what we're working with. And it's important to understand that because I think a lot of times we come at this as chiropractors from the conservative care realm. Many of us are looking for natural solutions and this is what is reality, this is what's happening out there in your community with people each and every day. So while for us, for somebody that takes no medications, it's like, oh my gosh, you're prescribing me an opioid, you're prescribing me an nsaid. Is there another path? Quite frankly, if somebody's already taking two, three, four medications or more, there's probably a less of a barrier entry. What's one more. In other words, now what's one more should be almost the biggest deal because chances are there's a complete drug interactions that could potentially happen, there's sensitization that's going to happen. It only becomes that much more challenging when somebody's taking more medications. Yet the irony in the dichotomy is that I'm imagining the more medications you take, what's one more becomes a real thing. So with over 50% of the people in your community right now, adults taking at least one medication over any 30 day period, that's what's going on. So when they are instructed that, that hey, movement is key, taking an active or a proactive role is absolutely critical. That's different than what they've heard in the past. Especially if there's somebody with multiple medications to fix or manage the problem, quote unquote. Getting in there and being more proactive with their health might be something that they just never heard before. And it doesn't mean that they're silly or foolish for making the choices that they have. It might just be an exposure issue. And us as chiropractors need to always be aware of that as, as we go through our patient communication because you have to meet people where they're at and not everybody's coming with the same set of expectations, not everybody's coming with the same previous experience into your practice when they're looking for relief or looking for improved quality of life. And we as providers, all of us need to really understand that. So there's quite a few findings in this study. We're gonna hit quite a few here and there's a lot of take home messages here. So NSAIDs were the most frequently endorsed medication for the treatment of both acute and chronic low back pain as a first line treat. So NSAIDs, top dog, no questions asked. We do know there are thousands upon thousands of deaths due to NSAIDS each and every year. And I believe the stat was around 100,000 visits to the emergency room each and every year due to NSAIDs as well. So are they safe? You know that's, that's a, that's, that's a tough question to answer, right. Compared to the deaths to how often it's taken, they're probably relatively safe. But, but you certainly don't wanna be one of those thousands of deaths per year that occur and there are risks and there's many people out there again tying back into what do people know about their body, their health and what's going on in healthcare? Not very much. So many People believe NSAIDS to be entirely safe, that there's almost zero risk and it's just not true. So when you look at the literature, nearly all guidelines included, nearly all the guidelines included in this study recommended non pharmacological treatments for back pain. And while this study did not focus on the non pharmacological aspect, they say it's worth highlighting that early exposure to non guideline concordant care, AKA opioids in their case may predispose patients in transitioning from acute to chronic low back pain. And this is an important distinction. Now it's sort of, it can be sort of a duh more than an aha. However, it's important to note that this is being notated in the literature and it's a very, very good thing because five to 10 years ago you just wouldn't have seen that. And what they're basically saying, I'll reverse engineer what they're saying is when people get subpar recommendations up front, when they get opioids sooner, ra, you know, not sooner rather than later, sooner at all. Whether it's sooner or later, there's an increased likelihood that that individual is going to eventually transition from acute to chronic pain, AKA the, the problem wasn't taken care of. Not only are opioids highly addictive, they don't do a very good job. They can knock out pain in a very short stretch at a very high level, which is why part of why they're so addictive. But if the individual has a biomechanical challenge, if the individual has a lack of movement as a primary concern, whether it's thoughts, traumas, toxins, if we bring it back 125 years ago, but they have a lack of movement, if their diet stinks, if they're super stressed out, opioids, are they going to really correct the problem long term? By and large we've seen the answer to that is a resounding no. So other factors involved in formulating recommendations, you know, they're saying from the physician perspective are balancing the benefits versus the harms, cost effectiveness and feasibility. So can you get access to the care? That's basically what I interpret. Feasibility, cost effectiveness, super important. You know, high, high, high cash based services are just tough, it's tough for somebody to afford, let's just say a health care intervention that's $30,000 if they make $30,000 a year. So not everything needs to be erased to a bottom and cost effectiveness needs to be taken within the context of what's out there. But there are ends of the Bell shaped curve and absolutes. Right. And certainly the benefit versus harm. So they bring up an example of a randomized control study of more than 1100 patients. They found that acetaminophen was not better than placebo in recovery time, pain, disability, function, global change, sleep or quality of life. And this study was cited in six of the clinical practice guidelines, with three recommending acetaminophen and one of which recommended as a first line for acute low back pain, and two recommending it as a first first line for chronic low back pain. So if this isn't the definition of insanity of what goes on in the literature, and I'm so happy the people who put the study we're highlighting today put this kind of stuff in here because again, I tie it back to what can we take away with our patients each and every day? Well, we can take away the fact that there are randomized controlled trials, which everybody holds to a very, very high standard, I guess, so to speak. Or you look at that with a high level of certainty. And, and this is a lot of people. And they said, hey, acetaminophen, no better than placebo. There's nothing wrong with placebo in my mind. But acetaminophen, if it can't beat that in anything, we're talking it didn't beat it in pain, recovery time, disability, et cetera, et cetera. Yet then in three of the six clinical practice guidelines it was recommended and in three as a first line treatment for either acute or chronic low back pain. Absolute insanity. And this is where I think we need to hold our healthcare professionals more accountable. We need to hold our healthcare system more accountable, because it's just crazy that it would be no better than placebo yet recommended. And we know that there are harms, placebo, do no harm. If it's no better than placebo, recommend placebo. Right. So when we trace these things back, sometimes the literature can just be maddening. But I love studies like this that point it out so we can take a look at it, critically, analyze it, and make meaningful decisions in how we go about our care and how we communicate our care to our community, which is one of the most important things. So in this case as well, they highlighted with some of these medications that associated harms were described to greatly outweigh the potential for benefit in patients with low back pain, despite some clinical benefit with acute low back pain. And that again was for acetaminophen. So I think when we're looking at harms, we're looking at that balancing point between harms and benefit. Acetaminophen just seems to fall off the map. Opioids, of course, should in my opinion, practically never be prescribed for anything neuromusculoskeletal related outside of red flags or cancer pain. So there's just a lot of great stuff in this study pointing out, quite frankly the challenges that, that we as conservative healthcare providers still have to overcome to have people understand and recommend who we are and what we do. But every time there's that challenge, the other thing to think about and consider, and I earnestly believe this, that is also your opportunity, that's your opportunity in your community to get out there to tell a different story, to differentiate yourself, to showcase what's true and what's right and to change lives meaningfully in the process. So they also highlighted a Cochrane review for antidepressants for low back pain. And of the seven studies, five reported no difference in pain between antidepressants and placebo without any benefit achieved at two weeks that was clinically meaningful. So what is the bottom line with this as they point out future directions? I love these quote, future research should seek to establish consensus on guideline recommended care. Duh. They also, you should stop recommending medications that have little to no demonstrated clinical benefit. That seems obvious. And also they point out there is little agreement amongst clinical practice guidelines in recommendations for antidepressants, acetaminophen and opioids, including tramadol. This disagreement is likely a reflection, the researchers say, of the varying weight placed by the individual guideline experts in interpreting the supporting literature, accessibility, cost and consideration of potential harms. So here is the really good news about this study. It points out the fact that by and large medications for low back pain are not the way to go. And it points it out looking at literally the clinical practice guidelines in going medication by medication. So powerful stuff to keep in mind. Again to me this is more fuel for who we are and what we do. Showcasing this that medications can be a great bandaid temporarily but somehow over the course of however many years there's been this belief in this insidious nature that has gone from hey, it can be a good thing in an acute state to help get you over the hump to it's the fix or it's the management. And we've seen that take its effect on so many people the three times a year on the injections and they're just getting worse over time. That's slippery slope to surgery. We've seen it so many times with the opioid epidemic We've seen it so many times with research that has showcased medication is not, is not a long term solution for neuromusculoskeletal complaints an overwhelming majority of the time. What is? Making sure you decrease inflammation, ensuring that you get proper movement patterns. I like to say segmental, regional and whole body, and quite frankly, keeping a positive mental attitude. Now, us as chiropractors, here's the beauty. We can directly, and many of us do, each and every day impact all three aspects. We show up with a great attitude, empowering our patients to take control of their health and be proactive. We certainly have the knowledge and expertise to help guide them on fueling the good stuff, decreasing inflammation, whether that's through the modalities that we offer or whether most of the time it's through the diet. You can't outwork your mouth, as they say, say so you know, improving the diet to decrease chronic inflammation long term. And then the third component, movement, of course we have that on lockdown. So going through your movement assessments, going through your physical examination, understanding what's going on with the patient and then adjusting prescribing exercises, getting in with rehab as necessary to support that segmental, regional and whole body movement. So a great study pointing out many of the flaws that are occurring. But for each one of those flaws, we have the opportunity to educate, to inform and to inspire people in our community to take positive steps towards relief. So I hope you have a fantastic week in practice. Before we wrap up, if you are somebody who is interested in orthotics, or if you're somebody who's never been interested in orthotics, head over to pro.powerstep.com sample pick yourself up a sample pair of Power Step orthotics. 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So if you are looking for that next step in your career, whether you're a veteran doc, whether you are a new doc, head over to chiromatchmakers.com on the flip side of that, if you're listening to this and you are thinking about adding on a chiropractic assistant or a new associate DC into your practice right now, you need to take action. So if you're thinking about doing that this year, head over to Chiro Matchmakers, speak with one of our placement specialists. It takes a few months to find a perfect ideal fit for your practice. They're just the power is with the associates. Right now there are five times as many jobs out there as there are associates. So it takes a little bit extra time. You need to be competitive. And at Chiro Matchmakers we go through an extensive behavioral assessment interview, vetting, sourcing, we can take care of all of that. So you don't need to. We know how hiring can be stressful and we like to say, and we've seen it time and time again, I've seen it. 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Sam.