438- The Impact of Chiropractic on Tramadol Prescriptions in Radicular 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 Langmaid. This week we are back with more research and it is a good one. It is all around chiropractic adjustments, chiropractic spinal manipulation and the likelihood of tramadol prescription in adults with radicular low back pain. A big study, lots of take home messages and also some just positioning of how you can better communicate with your patients who are, whether you like it or not, making decisions about their care and treatment day in and day out, depending upon how they wake up, how they feel, what is the light at the end of the tunnel, et cetera. We're gonna dive into all of this and more on today's episode. Before we get started, I wanna say a few words about Patient Pilot. If you're looking to reactivate more of your inactive patients, in most chiropractic practices, 90% of your patients in your EHR are inactive. And if you're not okay with that and you shouldn't be, you should be doing something proactively to generate as many easy and fast reactivations as possible. That's what Patient Pilot does. If you'd like to learn about how we do that and if we can help you, head over to the smartchiropractor.com, schedule a demo with our team and we'll walk you through and answer all your questions. SmartChiroPractor.com we'll drop that link down below the SmartChiroPractor.com but as I said at the top on today's episode, we're talking all about a new research study. The title of it I said earlier, I'll say it again and I'll also drop a link down in the show notes. This was in BMJ open and it is titled Chiropractic Spinal Manipulation and likelihood of Tramadol Prescription in Adults with Radicular Low Back Pain. A retrospective COHORT study using U.S. data. Tramadol, what is it? We hear about it all the time. I can tell you I've heard about it for years and if I had to really make a guesstimate on exactly what it was, I would have been a little bit lost. But this set the record straight right from the get go. It is an atypical synthetic opioid that's Interesting. It's an atypical, so not typical. It's a synthetic opioid at its core. And it comparatively has lower potency than an opioid medication. And that's why it's often been prescribed for low back pain. So I knew it was a pain relieving medication often recommended for people that had radicular symptomatology. I did not know that it actually was a synthetic opioid. So while previous studies have shown that people with low back pain that get chiropractic adjustments are far less likely to be, as a matter of fact, it gets cut in more than half. Far less likely to be prescribed any opioids. There has been no study except for this one to date that is focused specifically on tramadol. Now we touched on the fact that tramadol is atypical. Now why is that the case? Well, primarily because it has actually dual mechanisms of action. One, it does stimulate opioid receptors. It also inhibits norepinephrine and serotonin reuptake. That is what makes tramadol a bit different. Now, the strength of tramadol measured against morphine milligram equivalents, which is kind of their standard, is low because when you look at morphine, it's a 1.0 on the MME. Morphine milligram equivalents, when we look at tramadol, it's a 0.2, so about 20% of the strength. Interestingly, it also is short acting with a half life of approximately six hours. What do I hear when I read that? That you got to take a lot of it. And quite frankly, people can become sensitized. Something has a short half life, that means it works for a short amount of time. Good news is it's relatively low dose compared to morphine. Bad news, synthetic opioids are brutal. And with a short half life, this means you're gonna be eating the stuff like candy very quickly to get the response. And that's inherently what I've seen in my experience, seeing a lot of people over the course of my career and many people in the orthopedic groups I was a part of that were already advanced in their care and treatment options. There's a lot of people taking tramadol and there are very few. When I asked the direct question, how's that working for you? That said, awesome. Nearly everybody. Now, of course they were sitting in front of me, so it might have been a slightly biased group, but when they're sitting in front of me, almost everybody's like, I can't it doesn't. And, and that's what I've seen historically to be the case. Now, that's not nuanced, and nuances are important, Meaning it may have worked briefly before the patient was sensitized, it may have worked when they first started. But as acute pain becomes chronic, and we've discussed this a few times on this podcast, it just changes. It changes how every human being interacts with physically, mentally, physiologically, with the pain. There is just such a big difference between addressing something in an acute phase and getting on and getting out of that pain and moving into a subacute and or chronic state, which just compounds the challenges exponentially. So in the US We've seen Tramadol prescribed in place of stronger opioids because it's perceived to be a big air quotes here, safer alternative. Have we ever heard that before? I've heard that many times, and it's very rarely panned out with fewer side effects overall. But there are several major clinical practice guidelines that do not provide recommendations for tramadol prescriptions for low back pain. This is probably gonna start to sound really familiar with a lot of other opioids. For some reason, these things are still prescribed all the time, every day. Yet they're pretty much guideline discordant, not particularly recommended, and not very effective. Yet in many cases, these are still prescribed. That is a problem. Why is this a problem? Because globally, tramadol is the most consumed opioid. It's number one. It's at the top of the heap. There's probably people in your practice right now that are taking it. And according to one study, earlier study, in the US overall, opioid prescriptions slightly declined from 2005 to 2018. And we've discussed this a bit as well. There was a lot of progress made from early 2000s right up until 2018. You're gonna notice that's about a magic number right there. You can already know what's coming in 2019 that changed this. But there was a lot of progress made in terms of decreasing over opioids, synthetic opioids, you name it. They're all in the same family of medications. And they all inherently, whether safer or more risky, they all are in the same bucket. They all have big risks, big challenges, and very few upsides. So in 2018, from early 2000 to 2018, these things were seen to decline. However, prescription of Tramadol actually increased during this period. Why? Because while many doctors were correctly able to say that they were not prescribing opioids or x Y and Z opioids, as often, they're skewing the data and they're prescribing synthetic opioids out the back, quote unquote of their office. And it's not being reported in the studies. So it shows that opioids are being decreased while tramadol is increasing. It doesn't say what the net net is on that, but I can tell you it's not very inspiring. And then, of course, we know what came in 2019 that shifted the entire world and shifted the entire world of opioid medications to be prescribed and used and abused far greater than ever in history. Because of the challenges associated with being able to get out and do what's necessary, which is see movement based healthcare providers and ultimately be outside and have movement. I mean, movement based healthcare is where it's at. It's how our body heals. There is very little deviation from that. And when that was put into a state of lockdown, quite literally, that made things challenging for people dealing with chronic pain. No question about that. So tramadol does still carry the risks associated with chronic and persistent opioid use. So it is still, it's synthetic. Does that mean it's better or worse? You could make, you know, you could make arguments one way or the other, it's less potent. You could make an argument one way or the other. Half life is short, it's being prescribed a lot, and it's quote, unquote deemed a safe alternative. We've heard this story before, but let's talk about the good side of the coin and then we'll hash out what these researchers come to find. So, spinal adjustments, chiropractic adjustments have been found to be effective for radicular low back pain and are recommended by numerous practice guidelines. We've touched upon just about every one of them for the treatment of this condition. So there have been prior studies that have proposed a few different reasons why there might be an association between receiving chiropractic care and reduced opioid prescribing. Number one is the most painfully obvious one, which is when you receive spinal manipulation first, chiropractic adjustments first, they're really effective. And when you have better functional ability, decreased pain and increased mobility, you're far less likely to need an opioid or be prescribed an opioid or seek an opioid, because you're actually improving, you're feeling better. Pretty much the most obvious one. Second, of course, are that we as chiropractors do not prescribe opioid medications. So if you see a chiropractor on an initial visit, you're not gonna be prescribed an opioid right then and you're probably gonna have the opportunity to heal. And the good news about radicular low back pain, disc issues causing compression is discs do tend to heal more often than not. So even just on the elapsed time, do chiropractic adjustments help as a mechanism of action have been clearly defined? Absolutely. Does just the time elapsed between seeing a chiropractor receiving care and potentially seeing a medical doctor down the road that just elapsed time between those two visits allow the body to heal in and amongst itself, even if no adjustment was given? You add on because of the natural course, natural history. When you add on chiropractic care now, you start accelerating results. And these things have compounding effects that result in far less people seeking and or being prescribed opioids. Because many are better, most are on the road to recovery. And that's a really, really good thing. So in this study, they looked at adults age 18 through 50. They had to sort through, I think it was tens or hundreds of millions of different files. And they kind of narrowed it down to a couple thousand people based upon a pretty stringent criteria. And what they found was this. The proportion of patients who received a tramadol prescription over a one year follow up after the initial visit for radicular low back pain was lower in the chiropractic cohort compared to the usual care cohort. And how did this shake out? After propensity matching, 1.3% of the chiropractic cohort had received a tramadol prescription, compared with 4% of the usual medical care cohort. So you are just about 7. It did. So we went from 4% to 1.3. 4% to 2% would be a 50% reduction to 1.3%. You're looking at nearly a 75% reduction in those individuals who had received that medication. Big, big deal there. So as they highlight here as well, analysis of care utilization markers suggests that patients in the usual medical care cohort seldom received chiropractic following the index or the initial visit date. In addition, both cohorts demonstrated similar utilization of usual medical care. NSAIDs, PT, lumbar imaging. Therefore, and this is a really, really interesting point, the cohorts were different and distinct in respect to chiropractic use, but similar in usual medical care. So here's what that's saying kind of in plain English, people were not very likely to be recommended chiropractic care if they saw a medical doctor first, if they started unusual care, they pretty much went down that and there was very little crossover. Now side plug, if you're interested in building relationships with other healthcare providers and if anything shows that there's opportunity, it's research like this. Talk about mass opportunity. The evidence based chiropractor MD connection program is where it's at. Make it super easy. You can learn more@the evidencebasedchiropractor.com My opinion, at the cost of reaching out, which is so, so low. The program is dirt cheap, super easy to implement. There's like no chiropractor practicing that. Really, if you haven't even inkling for wanting to get increased referrals, it's how you do it. So that aside, this showcases that if you saw a chiropractor first that was, you know, of course you received chiropractic care, but it didn't really alter the use of medical care. Now it did alter the tramadol prescription, but people still received follow up care for from their medical doctor. However, if they started in a medical practice, they typically did not receive follow up care from a chiropractor. So these things did not cross over. Really, really interesting to highlight there. So they found a low. When I talk about 1% and 4% you might say that sounds a little low. And if you thought that, you are 100% correct. So in previous studies we saw anywhere from 16 to 35% of people in a radicular low back pain cohort being prescribed tramadol. So a lot of people, like a good chunk of people with radicular low back pain are being prescribed tramadol. In this study it was a little bit lower. And they highlight the fact that it was probably due to the segmenting of people. One, they excluded patients who had received opioids over the preceding year. They had excluded patients with serious pathology who would likely have an opioid prescription excluding and they included patients with a new radicular low back pain diagnosis. So the segmenting of these patients probably skewed the data of tramadol prescription slightly lower than actually happens out there in practice. However, man, when somebody saw a chiropractor, they cut that down dramatically. And that should be inspiring, it should be impactful and it should be something that you can, number one, have intelligent conversations with your patients about, especially those that might be recovering a little bit slower, they might be moving a little bit slower in your practice. And there is an allure if they've been not hitting their Goals and expectations as quickly as they would like. I'm not even talking about what you've set. This is always about the patient, right? They have their own agenda and if they're moving a little slower than they want, they might start hearing things from people at work, friends, family that influence them to maybe go more of a medication based route. So this all ties back to having accurate, clear communication, setting expectations, understanding goals, doing great examinations and evaluations so you can set the stage for success for your patients, number one, for your results in your practice, number two. All of these things come together. Now these researchers in this study found at the end quote. Our findings are similar to previous studies which found that patients receiving chiropractic spinal manipulation with for low back pain were less likely to receive an opioid, benzodiazepine or gabapentin prescription. These medications are similarly not endorsed by clinical practice guidelines for treating low back pain. Accordingly, our study adds to the existing evidence that patients initiating care for low back pain with chiropractic spinal manipulation are more likely to enter a guideline concordant pathway with respect to medication prescribing. So I'll get on the soapbox just for a moment. I read stuff like that and it makes me happy because it showcases the fact of what we're doing with movement based healthcare is the right thing. The research has proven that out, the results showcase that. And when people come in to see us, they're really happy. High patient satisfaction. It drives me nuts because I also. It blows my mind that studies can be produced. I mean this is just. We just see this, we could. How many studies of these can you pick out? Dozens of studies that highlight the fact that that many doctors out there are guideline discordant. They're prescribing medications off label. Guideline discordant at best, off label, in a dangerous territory at worst. And there's just absolutely no ramification. All of us took the Hippocratic oath to do no harm. Many doctors out there need to look at that and they really need to take that to heart and understand are they really doing no harm? Are they really making the best decisions for their patients? Because I can make a strong argument that there's a lot of doctors and it ain't dozens, it ain't hundreds, it's probably in the thousands that are making potentially dangerous and at the bare minimum poor decisions for their patients with neuromusculoskeletal care each and every day. Now here's the good news on that. That provides us an opportunity to stand clear. That adds us an opportunity to stand up, so to speak, to bring our head and shoulders above the crowd. How? By communicating clearly, by delivering results, by helping people understand that there is a better way, and by making the right referral when there's not. That is how we can change the tide of this. That is why I appreciate docs like you listening into this podcast each and every week, hopefully learning a thing or two, maybe getting a smile along the way. And if that's true, I would love it if you would leave a rating or review that helps us reach more and more docs. Additionally, you probably have seen the videos online, but if you're interested in objective assessments of the cervical spine, you have to check out neck care to neckcare.com great URL. I'm gonna drop it down below, but you won't forget that neckcare.com reliable assessments and exercises for neuromusculoskeletal control, proprioception, range of motion, and sensory Motor integration. I have one of these units about six feet away from me right now. They are awesome. The technology is the best in class and it's not even close. So if you are interested in objective assessments of the cervical spine, head over to neckcare.com Other than that, thank you for being a chiropractor. Thank you for tuning in. Have an awesome week in practice and I will talk to you soon.

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