343- Reducing Benzodiazepine's with Chiropractic Care

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 Langmaid. On today's episode, we're back with research. This was in British Medical Journal super powerful paper, tons of information that we should be aware of as chiropractors. It's titled association between Chiropractic Spinal Manipulative Therapy and Benzodiazepine Prescriptions in Patients with Radicular Low Back Pain. This is a retrospective cohort study using real world data from from the usa. So lot of great data points that all of us should be aware of as chiropractors. Some scary data points, but also the challenge is always the opportunity. So we'll frame it in a way of how you can have great communications with your patients and with other healthcare providers. Before we get started, I wanna talk about the Payday Practice. It's a new book just released by Dr. Jason Deutsch and myself. You can get a free copy. We are gifting a copy to Evidence Based Chiropractor and smart chiropractor audiences. The Payday practice dot com. This book is all around showcasing a step by step process on how you can begin generating monthly recurring revenue in your practice that meets or exceeds your monthly expenses. That is about freedom, it's about reducing stress, it's about increasing revenue and having a more complete patient experience. You can download it for a limited time for free. It's going to be on Amazon soon, but you can get a digital copy for free at the Payday Practice right now. But today's episode, we are talking research. As I said, this was a fantastic new study that came out in 2021 and it basically looked at when somebody sees a chiropractor or a medical provider, what's going on? Does it affect how benzodiazepine prescriptions are made? Does it affect how often they're filled? That is really the essence of what this looked at. Let's dive into the study itself. If you're not familiar with benzodiazepines, they're a class of psychoactive medications increasingly prescribed for patients with low back pain and very commonly used in patients with ridicular complaints. Now, we'll talk about whether that's a justified use or not in a few minutes. But they are psychoactive medications and I think all of us, if we ask our Patients, what they take. We, we probably have seen many patients that are on benzodiazepine. So previous research has indicated that any patient receiving care by a chiropractor for low back pain has a reduced likelihood of filling an opioid prescription compared to other provider types. We've reviewed a couple different studies that have highlighted that on this podcast. And we all know of course as chiropractors, we can't prescribe opioids, we can't prescribe medications, we cannot prescribe benzodiazepines within our scope. And the question is, well, is it causation or correlation? This typically is the question, right? Is it because we're unable to prescribe the medication that commonly, although we'll examine this study, commonly we see reduced opioid prescriptions or is it causation? And the answer that I've seen over time is it's a little bit of both. There's a correlation between who you go and see first and the recommendations given in the scope of practice. And but there also is the causation where if we're able to eliminate that pain, improve the quality of life, empower patients with movement based care, well, they never then are going to go after that medication. The difference is, and where we see that is the long term follow up. So causation, I always think causation happens long term, meaning if they don't fill it, you know, 12 months from now, six months from now, 18 months from now, then chances are you really did a great job taking care of the issue that brought them in the first place. That would be a causation type effect in my case or, or what I believe. Whereas if it is the one month, three month, that's more correlation, well they're seeing you, you do this and they're under your care. So a little bit of both. Now one study previously released, it highlighted military personnel and they received four acupuncture treatments for back pain or other conditions over a one year period of time and they saw a 14% reduction in benzodiazepine utilization during a 60 day follow up window. So that's some of the study that was really done previously, but there's nothing really that's looked aggressively at whether chiropractic care can make an impact on that. So benzodiazepines are sedative hypnotic medications, then they act on the central nervous system. We'll touch on that in a few minutes. And why that can be such a challenge. But the number of physician visits during which benzodiazepines were prescribed for back pain and chronic pain. More than tripled in the United States between 2003 and 2015. That's more than tripled between 2008 and 2015. 11.5% of opioid naive adults were prescribed benzodiazepines over a 12 month window after an index for a low back pain diagnosis. 27% of low back pain patients reported being recommended benzodiazepines by a medical doctor in the past 12 months. So this is real deal. Over a quarter of people that had low back pain, that visited a medical provider were prescribed benzodiazepines just a couple years back and that rate tripled in the 10, 5, 7 year period before it. That is a big deal. And it's something that's walking into our practices that we have to be aware of and deal with one way or the other each and every day. Now here's the kicker. There's been no evidence whatsoever, no conclusive evidence that benzodiazepines produce any analgesic effect. Yes, you heard that correctly, which is insane. And what are the adverse effects? Sedation, addiction, increased risk of suicide. Dependence occurs in 20 to 100% of those individuals taking benzodiazepines for at least one month. 20 to 100%. And although these medications have been prescribed increasingly at an alarmingly increasing rate for low back pain, there's no evidence to support their use to take care of this condition. As a matter of fact, we can look at some of these clinical practice guidelines from the National Institute for Health and Care Excellence, Veterans affairs and Department of Defense Global Spine Care Initiative, Belgian Healthcare Knowledge Center. They all recommended against prescribing benzodiazepines for low back pain. And the American College of Physicians concluded there was insufficient evidence for their effectiveness and in either acute or subacute low back pain. So you think that the Hippocratic oath starts with do no harm and you want to minimize or eliminate harms. The research unfortunately tells us different things happen in clinical practice each and every day. Systematic reviews for chiropractic or spinal manipulative therapy, however, have found evidence supporting this treatment for acute, chronic and radicular low back pain, while also documenting its safety. Powerful stuff to be aware of. Powerful stuff to to know. Now, how does spinal manipulative therapy or chiropractic care alleviate low back pain? There's quite a few different mechanisms, but it may relax hypertonic or abnormally tight muscles, release adhesion surrounding lumbar disc or facet joints, and lead to improved range of motion, especially with those individuals with radicular pain. So a lot of different mechanisms on how we help. Very few if any mechanisms on how these medications help. Yet we see. I don't believe that the prescriptions for chiropractic care have increased 300% over the last seven years, but they certainly have with a medication that has a lot of harms and very little upside. This study looked at the TriNetX National Research Network. I hadn't heard of that before, but apparently this has 73 million patients in 52 healthcare organizations. HCOS at the time of sampling they looked at adults between the ages of 18 and 49 with an incident of radicular low back pain and that resulted. There was a lot of sorting, segmenting and searching through the data, but basically they came up with just a little bit. Under 10,000 patients in each cohort. One cohort received chiropractic, the other did not. And what did they find? The odds of receiving benzodiazepine prescription were lower in the chiropractic spinal manipulative therapy cohort over all follow up windows with statistical significance in each window. So it wasn't just that the numbers looked a little better. Isn't that nice? It is statistically significant across all time windows. Do we think chiropractic should be offered earlier on in care? Do we think it should be offered before any medications? I think the answer to that is a conclusive yes at this point in time. Now it's on us to get out there and make sure it happens. So what were some of the discussion points findings here? Recipients of spinal manipular therapy had significantly reduced odds of benzodiazepine prescription for each window. And Those windows were 3 months, 6 months and 12 month follow up. So a nice tale on this study. So this was a powerful study. I love it. One of the other findings they had were quote, patients entering this pathway for radicular low back pain are more likely to receive guideline concordant care with respect to benzodiazepine prescription. What pathway was that? That was the pathway that included chiropractic and spinal manipulative therapy. So in guideline concordance boggles my mind that we're talking about this in studies year after year after year. Yet the clinical practice can be non guideline discordant and there's no teeth whatsoever that goes that direction. So frustrations aside, this is our opportunity to get out there and inform our communities. Number one, I feel like very few people have any idea that benzodiazepines essentially have no pain relieving effect whatsoever. They make you tired and they make you hopefully go to sleep and forget about the pain. But they have no analgesic effects whatsoever. So they don't take care of the problem, they distract your brain from the problem, but they have nothing in the vein of actually taking care of the issue at hand. Secondarily, we just listed them off a laundry list of clinical practice guidelines that recommend against, not even limited against, the prescription of these medications. Yet the prescription of These medications over 7 year window increased 300% for people with radicular low back pain. Absolutely incredible. We know that from a compressive standpoint, there's three things that can cause radicular pain. If the nerve is being physically irritated, meaning a physical compression, bone, disc or ligament. Benzodiazepines aren't going to do too much for bone, disc or ligament. But movement based care can make a huge impact. Secondarily, it could be chemical irritation, of course, that irritates the nerve and causes radicular symptomatology. A lot of the times that chemical irritation is due to inflammation in the area. So you want not only a pain relieving effect, but again, this ties back to how important movement based care is to receive full benefit, to get better and to quote, unquote, fix the problem. And it also takes two to tango. So as you're speaking with your patients, helping them understand this isn't to dog other healthcare professions or to put anybody else down, but many people believe that when they receive that prescription, that is the fix, that's what's going to help them. And we see this happen all the time because people will come into your practice and not receiving great results from the medication. So they're still taking the medication and they come into our practices to receive care. This is the backwards nature of things. So they'll continue to take the medication that doesn't work, come into our practices to receive care and hopefully get better while we're fighting essentially an uphill battle against the negative effects in some ways of these medications. Yet on the other side of the coin, people will discontinue chiropractic care, go to take medications or go to have a surgical intervention and, and 99.9% of the time they don't continue with chiropractic care during that. So this is just the, this is the landscape that we're up against and the lack of understanding. And I think that that is really the core essence of this. So as you get out there, hopefully with the information that you learn on this Podcast each week. Hopefully many of the stats that we touched on today, utilizing this in two ways in your practice is so, so important. One is, well, maybe three ways. One. One is educating yourself as far as what's out there, what does the research say and how can I apply it to my practice? Then there's two applications in your practice. One is applying it to the communications you have with your community and your patients. Doing it in a professional way. Doing it in a way that is empowering, not demeaning, and showcasing to people the truth about their body and what's going on with their healthcare. It's exquisitely important. And sometimes that's a fine line to ride between telling the truth and not seeming like you're cynical or bitter about what's going on. But it's an important line to ride. The second portion of that, the second application is communicating with other healthcare professionals. I firmly believe that most other healthcare professionals prescribing these medications aren't doing it because they want people to become dependent upon benzodiazepines or because they're doing it because they know they're ineffective. They're doing it because they don't know a better path. That is where we've helped hundreds, probably over a thousand chiropractors at this point in time with the Evidence Based Chiropractor MD Marketing program to help you bridge that gap through research, through systems and processes that can consistently produce referrals into your practice. Yes. Is it good for your business? Absolutely. But it's a heck of a lot better for the people in your community getting the care that they need instead of going down these other roads. That's why this information is so, so powerful and why I thank you for taking time out of your week to tune into this podcast each and every week to learn more about healthcare, to learn more about what's going on in the research, and to be able to hopefully learn how to apply it to your conversations you're having in your practice. So if you've not left us a rating or review, whether you're listening on itunes or you're listening on Spotify, please do so. It helps more and more docs find out about the podcast if you are so kind to leave even feedback on a line or two of text a review of it, it was so, so helpful. I love seeing it and I greatly, greatly appreciate it. I know we have 10,000 plus docs listening to this podcast each and every week and I couldn't be more humbled by that. My ask would be, please take a moment out of your day. Share what you think about it. That helps. More Docs Find out about the Podcast before we wrap up today, I want to talk a few minutes about Power Step Power Step or the athotics I use myself. My father is used to great success. They're created by a podiatrist over 30 years ago. I love them. And Power Step for listeners of the Evidence Based Chiropractor podcast, they're willing to hook you up with a free sample pair pro.powerstep.com sample pro powerstep.com sample we'll drop that link down below. Fantastic orthotics and I can't speak highly enough about them. And finally, before we wrap up, if you are looking to add a chiropractic assistant or a chiropractic associate to your practice this year, please check out what's going on over@chiromatchmakers.com helped 500/plus practices find the right People Staff turnover Hiring the wrong people can cost you six figures or more in your practice. Time, effort, energy, stress. We have that interview process, the sourcing, vetting, interview and placing process down to a science Chiromatchmakers.com, there's interview guides over there, blogs to help you out and of course if you'd like a concierge level of service from front to back, we we can help you with that as well. Have a fantastic week in practice and I will talk to you soon.

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