45% of Stenosis Patients Are Already on Pain Meds Before They See You | #545

Hello and welcome to The Evidence Based Chiropractor. I'm your host, Dr. Jeff Langmaid. On today's episode, we are back with more brand new research and it's a cool one. This is all about analgesic use before and after chiropractic care for lumbar stenosis. So stay tuned. Super pragmatic, great clinical pearls and take-home messages. We are going to dive in in one moment. Before we do, shout out to a few partners. Leander Tables, you can save $750 on their Series 950 table using the code EBC2026, as well as Shockwave Centers of America. You can save $500 off a shockwave unit and get a free cart. Over $1,200 in savings right there. And of course, we will drop those links down in the show notes. Now, as I said at the top, today's episode all about research. Title of the study: Use of Prescribed Analgesics Before and After a Standardized Chiropractic Care Program Among Patients with Lumbar Spinal Stenosis: A Nationwide Cohort Study. So this study kind of dives into what I'll call the intersection of some really important, again, pragmatic items. Chiropractic care, number one, spinal stenosis, probably something you see each and every day in practice. Medication use. Many of your patients probably on medications, whether they've told you or not. Patient safety. And really the big role that us as chiropractors can play in the healthcare system because patients with lumbar spinal stenosis are often taking pain medications. Absolutely no surprise. It's important just to be aware of that. These are people dealing with leg pain, reduced walking distance, neurogenic claudication, daily life limitations. Many of them are older and many have other health concerns as well. So by the time that they show up in your practice, they may have already been trying to manage their symptoms on their own using NSAIDs, opioids, you know, gabapentins, or some combination of all of those things. So we know that the clinical guidelines do not, not generally recommend analgesics as the primary strategy for lumbar spinal stenosis. The guidelines instead really emphasize non-pharmacological care, things like patient education, exercise, manual therapy, structured follow-up. Sounding familiar? A lot of what we do as chiropractors. And that's exactly why this study is so relevant. And this was a large nationwide cohort study out of Denmark. They looked at more than 7,000 patients with lumbar spinal with stenosis who had entered a standardized chiropractic care program. And really the question that they were trying to answer, the researchers, were what happened to prescribed analgesic use before, during, and after that chiropractic program? So the pattern was pretty interesting. Medication use rose before chiropractic care, actually peaked during the program, and then generally declined afterward. So, you know, does that mean that chiropractic care alone caused every bit of that decline? Well, not necessarily because this is an observational study, but it certainly supports the idea that we as chiropractors can be an important part of guideline-based non-drug management for lumbar stenosis. And that's kind of what we'll walk through in detail today. So this study was published, Chiropractic Manual Therapies, in 2026, brand new one. And again, they were looking at degenerative lumbar spinal stenosis. Uh, typically caused by degenerative changes that narrow, of course, spinal canal. Some patients that can compress neurovascular structures and then lead to the symptomatology that we all are familiar with— leg pain, neurological symptoms, really that classic neurogenic claudication. So many of these individuals are kind of like what I think about always looking for the grocery cart. Hey, when you go around the grocery store, uh, you know, are you able to make it around the store? If I have a cart under me, I can go forever. If you take that cart away, I'm looking for a chair. That's pretty much the classic, you know, symptomatology or classic life experience. So lumbar spinal stenosis does become more common with age. Time and gravity undefeated, right? This is a major issue for a lot of older adults. And this paper notes that lumbar spinal stenosis is among the most common causes of pain and disability in older adults and is a leading indication for spinal surgery in people over 65 years old. So this is a really big deal. This is not only about getting back some quality of life, this is about reducing the necessity for surgery in an ideal state. Not every patient every single time, but in many cases, many times. So this is not like a tiny niche condition. This is real-world spine care with real implications in your community. And the researchers were specifically interested in the analgesic use before the, before care. And this is where things kind of, I'll say, get interesting. They were tracking the medications, NSAIDs, again, opioids, gabapentins, et cetera. And the study included about 7,300 patients. And this was really between 2017 and 2022. And this was a structured chiropractic care pathway. So it wasn't kind of come in whenever you feel like it. It was a care plan. It was organized care. Um, and they used Danish registries to track the prescription use before, kind of during, and after. So the median age of the individuals in the study, 71 years old, and 52% were women. Now, 45% of the patients had used some type of analgesics in at least 2 of the 4 quarters before starting the chiropractic care program. So almost half of the people in this study were already established medication users before they entered the program. Talk about an opportunity just right there. Think about your community. Think about 50% of the people with symptomatic lumbar spinal stenosis having already be taking medication, probably not getting the result that they want. It's a massive opportunity for you. So when the researchers looked at quarterly use, they found 39%, uh, used medications in the first quarter of the year before the chiropractic care plan, and 57% during the chiropractic care plan, 48% in the final quarter of the year after the program. So use rose kind of heading into CARE, peaked around the start of the program, no surprise, 'cause they're looking for solutions clearly, and then declined afterward. So NSAID use was about 12%, opioid use about 11%, gabapentins about 6%, and during the program that went to NSAIDs at 19, opioids at 20, Massive opportunity there for us to make an impact. And gabapentins at about 17%. Now, one year after the program, NSAID and opioid use dropped close to where they were at baseline. NSAID use went back down to about 12%, opioid dropped to just under 14%. So the pattern was pretty clear. The patients appeared to be escalating medication use before and during the entry into the care program, likely because symptoms were getting worse and they're looking for a solution. No surprise there. And then many saw a reduction of prescriptions afterward.

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And there's another finding about how concentrated medication use was among— it's a relatively small group of the patients, but the top 10% of analgesic users accounted for 50% of the total NSAID use and 68% of the total opioid use. So this is a small group of patients that were really— they accounted for a disproportionately large share of the total medication exposure, especially opioids and gabapentins. So from a clinical perspective, this is important. And from a patient safety perspective, this is really, really important. And from a chiropractic positioning perspective, it continues to reinforce that us as chiropractors, we're not just taking care of aches and pains. We are part of a larger conservative care ecosystem, really, that can help patients move towards safer and more guideline-consistent care pathways. So analgesic use increased in the year before patients enrolled, which again makes a lot of sense clinically, as you can imagine. Patients don't enter a structured care pathway when everything's going great, right? They enter because the symptoms are becoming more disruptive, the life effect and life impact is getting greater. They might be walking less, sleeping worse, and all of this leads them to going into their primary care provider or the pain management doctor saying, what else can I take? That's just how it happens in the real world. So the rise in medication use before enrollment is probably very symptomatic of exactly that. But during the program, we see the peak of the use. Again, not surprising, 'cause at the start, that's like when the symptoms are probably the most intense or the most concerning to the patient. But after the care program, the use did decline. And that's important. Those were meaningful changes. They found that NSAIDs and opioid had reduced to baseline or below baseline levels. And that's a really, really important combination. Now, obviously our goal is their baseline is zero, right? Ideally, people are not taking opioids for spine-related conditions unless it's obviously prescribed by the right doctor. But unless, if it's a non-cancer issue and it's not directly after surgical intervention, it's a tough case to say any of those individuals should be taking opioid-based medications. But with this study, it highlights the fact that those that did and then escalated were able to get back down. And that's important because it showcases two things for who you are and what you do as a chiropractor. Number one, it highlights the fact that early intervention is critical. Imagine 10, 20%, those numbers of opioid users never going that direction. And that's just getting to those individuals earlier, right? We said, How did they get there in the first place? Well, they got there because they probably were taking something else. It quote unquote wasn't working. Well, clearly they have a mechanical problem. Literally, they have neurogenic claudication. So the medication is gonna provide symptomatic short-term relief at best, at best, with a host of side effects at best. So being able to get to patients upstream, whether you use MD Connection through the evidence-based chiropractor, build referral relationships, I just, I think it's a critical part of chiropractic practice that quite frankly, 98% of chiropractors aren't taking seriously or really doing any real work on. And it's just such a missed opportunity to help people in your community and to generate more revenue for your business. Now, the second component is those individuals that have gone the route of medication use. This study clearly shows the game's not over for them. If they can get in and see you, there's a really good opportunity for them to be able to decrease that over time. Again, out of scope for us to make the recommendations on decrease, But if the patient's doing well, often the doctor will pull back some of those medications. And quite frankly, depending upon how clear the patient communicates to their doctor, I bet you they can come down even farther because many doctors are gonna be, I'm gonna say conservative in their medication reduction. Where if the patient's saying, I'm looking to get off of these medications as quickly as possible, and I'm doing these other things and seeing good result, I got a feeling that the medication use can come down even farther with a little bit of directive behind it, let's put it that way. So lumbar spinal stenosis is super common. If you're taking care of older adults, you're probably seeing this every single day. And you know, it could be manifesting as their back hurts. Often it's gonna be, again, that really fast fatigue, the legs getting tired when they're walking around. The authors in this study clearly do state that the clinical guidelines discourage analgesic use as the main management strategy for lumbar spinal stenosis, which is, I'm going to say, really important. Should be pretty obvious to most doctors, but clearly it's not. So the onus does become on you, on me, to be able to get out there, have these communications with patients, but also with other Doctors. And it's not disparaging other pathways, it's not disparaging the other providers, it's just helping be the bridge solution. 'Cause many times, if we just really look at the facts, often if the patient is not in, let's say, physical therapy or physiotherapy, or they might be doing that and not getting the result that they want, the doctor's gonna look towards the medication or the advanced interventions. Why? Because they, that's the tools they know. So unless they know, who you are, what you do, and you've built that trust and help them understand that these are the types of patients that you take care of, if they are, they're never gonna guess it on their own. So getting out there, having those conversations, absolutely, absolutely important. And these are also great opportunities for you to teach and educate online, whether it's with reactivations, whether it's in your report of findings, or whether it's in just some of the copy or reels that you're shooting. Letting people know, you know, if you have spinal stenosis and you're relying more on pain medication as time goes on, you're not alone. There actually was a large study of 7,000 patients and they found medication use increased before people started a structured care plan that included chiropractic. But after the chiropractic program, medication use declined. So the big takeaway is that spinal stenosis needs a plan, not just pills. Education, movement, conservative care, chiropractic can all play a really important role. That's like, you can rewind this and just use that as a soundbite, use that to teach and educate as you get online. So this study again, 7,000 patients, lumbar spinal stenosis increasing as our population continues to age. This continues to be more and more of an issue and more and more of an opportunity. Nearly half of the individuals were using analgesics and again, NSAIDs and opioids, the chiropractic program, and again, not onesies and twosies, but utilizing a systematic care plan Enabled people to reduce and some people to even get off the medications. And what's that a byproduct of? Them being able to functionally live their life better, which is really why they're in your practice. So as we wrap up today, big shout out to NovoPulse and their OA Recovery Program. If you don't have a structured osteoarthritis recovery program in your practice, check 'em out. I'm gonna drop the link down below. Diabetes Reversal Group, type 2 diabetes is walking into your practice each and every day. Diabetes Risk Group makes it easy to refer the patients over to them. They do the heavy lifting, the patient gets the benefit. It's a win-win-win, including your practice. A nice financial model there as well. As well as RehabFix's hybrid program. Grant Elliott has been a, a trailblazer, I'm gonna say, in online education and online care. He has now really brought that expertise to help you be able to do that, not by abandoning your brick and mortar, but being able to add to it using RehabFix's hybrid program. I'm gonna drop all those links down in the show notes. And if you have not left a rating or review for this podcast, I would deeply appreciate it if you'd take a moment and do so. Thank you so much for tuning in. Thank you for being a chiropractor. Have a fantastic week in practice, and I will talk to you soon.

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