517- How Pre-Existing Pain Medication Impacts Low Back Pain Recovery

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 brand new research and this one is all about the role of pre existing analgesic use and how that interplays with low back pain. Great study. Super applicable to a significant portion probably of your community and even a portion of your patients. We'll dive into what the research says, how to approach it with your patients and why it matters, all on today's episode. And before I get started, I want to give a shout out to both Leander Tables and Neckcare Neck Care, of course, the best cervical assessment tool on the market. You can check them out and get 10% off by mentioning that you listen to this podcast. I'll drop a link down in the show Notes and Leander tables $1,000 off their Series 950 some of the best tables out there by being a listener. So it pays to listen to this podcast each and every week, not only for the deals but also for the research. So without further ado, let's dive in and this is going to start with a question. And the question is, have you ever had a patient using pain meds for months, maybe years or longer than you think that they should be? You help them move better each day as a chiropractor, you help them understand what's going on with their function with the pain itself and you help them ultimately feel safer in their body by getting over fear, avoidance behaviors. Yet when we really dig under the hood, we see with some of our patients, medications still stick around. In this study, brand new one out of Denmark, title of it, the role of pre existing analgesic use and self efficacy for continued use of analgesics among patients with persistent low back pain. This came out of Denmark and it may give us probably what I'm going to call one of the clearest explanations of why this happens and more importantly what we can do, you and I about it as chiropractors. So it's all about self efficacy, medication use and low back pain. And the results were pretty eye opening. So we'll dive in of course again to what they studied, what changed, what didn't and how you can apply this in your practice. So this research article analyzed over 4700 adults. So really, really good sample size. With a standardized eight week education and exercise program built around helping people with persistent low back pain develop better self management skills. So they were really after three primary questions. Question number one, do patients change their pain medication use after a structured education or exercise program? That's a good one. Question number two, does self efficacy, their belief in their ability to manage their own pain, influence medication use? Another great question. And then question number three, does improvement in self efficacy over three months modify future medication behavior? So these questions are really important for some obvious reasons and some non obvious reasons. So number one, it's important because low back pain is still the leading cause of disability worldwide. Man, I sounded like a real New Englander. I said that it's still the cause of disability worldwide, the leading cause. So while it gets boring for us, you know, low back pain, low back pain, low back pain, the reason we talk about it so much is because it's still impacting so many people. This also matters because pain medications, they provide a limited benefit at best for low back pain and of course they come with serious risks. So it's something we really need to be tuned into. It's also because most guidelines now recommend a self managed, self focused, conservative, non pharmaceutical or pharmacological approach that's really important. And self efficacy is a major driver of whether patients use active or passive coping strategies. So especially analgesics, in the long term they're considered passive coping. So the real underlying question here was can we, you and I, help patients reduce their reliance on pain meds by providing them with improved confidence and an improved ability to self manage? So this one's not adjustment specific, but it is about what we do. And what we do is influence people in a positive way towards overcoming fear, avoidance behaviors, helping them understand their body, understand the difference between structure and function, and move people along. Of course the adjustments that you deliver, that's critical, it's a foundational component. But even with the removal of that, there's a lot of influence that you can have on patients, that meaningful influence. So let's take a look at some of the numbers because I think they're pretty powerful. So over half of the patients in this study, 56% were using analgesics at baseline. So this is, remember, not a chiropractic audience, right? This is a general low back pain audience. So over. But this is your community. It might not be your patients because your patients might have made different decisions, but this is your community. Over half of the patients in this study, probably half of your community, who reusing analgesics at the baseline. So this already starts to tell us how common long term paid med use is when people are seeking help for low back pain. Now, of those using analgesics at baseline, 66% continued after the program. Yes, you heard that right, 66% continued using them after the program, 34% discontinued. Now, patients not using analgesics at baseline, 89% stayed medication free, 11% started using meds. So, I mean, this tells us a lot and we're gonna unpack it in a moment. But one other thing was analgesic use at baseline was clearly the strongest predictor of use at 3 months. So the odds ratio was 9.79. Meaning if you started this program with medications, you were almost 10 times. Yes, you heard that correct. You were almost 10 times more likely to still be using them at three months. So that's massive. It's massive because it tells us what happens early on is really important. What you know, and this comes down to, you know, I'm just going to be blunt and straight about it. What are they seeing a medical doctor? Are they watching a lot of television telling them to take medications? Going to a medical doctor that's giving them bad information and bad advice? Not every time is every medical doctor giving bad information and bad advice, but it certainly is a much higher likelihood that they're gonna walk out with a prescription as opposed to walking in to, in this case, I'll say specifically a chiropractor's practice where that's highly unlikely. And when you look at that and say when they start an exercise program, if they're on medication, they're 10 times more likely to be on medication three months after that exercise program is completed. That tells us that there's a lot of dependency going on. And it might not even be pain relief at that point. It might be psychological, it might be habit. And if we go one level deeper with this, this is really important for you and I to be aware of why, Because a good chunk of people coming into your practice today, tomorrow are on pain medication. And even though, spoiler alert, even those that are not reporting it on their intake forms, there's probably a good portion that are. So asking that extra question potentially during your intake, really drilling down on it, not just as a line item, did they fill it out? Did they not? But really understanding is important and it's important because they might be doing things. I know this is shocking for us to believe, but if you're with a patient 10 minutes, 15 minutes, they're living another 23 hours and change Outside of your practice, if they're not coming daily, they're, they're living hundreds of hours between visits. Many of them do things we might not want in between the time between visits. Right. So it's important to unpack that and understand that because they're going to spend a minority of their time of their life obviously in your practice. And a fractional percentage of even the time that they're in pain will be physically in your practice. So understanding what they're doing when they're not in your practice is meaningful and important. Because even if they are doing everything that they should within your practice, if they're taking pain medications before they came in, there's a significantly higher likelihood they're gonna continue to take them on their way out the door unless you have an open conversation and understand exactly what's going on. So getting back to some of the numbers here. When self efficacy improved during the program, the absolute risk of medication dropped. So for baseline non users, for from 15% to 6%, for baseline users, 76% to 54%. And that's a massive reduction, especially for the people that were already using the medication. So this highlights a couple really important things. One, medication behavior is really sticky. You wanna think about a sticky product? Medication is one of those. Once patients were using medications, most of them kept using the medications even after an eight week evidence based program. And that's not a knock on the program. This is a true reflection of human behavior that's again impactful and important for us to understand. Pain meds do become habit and for many people they represent a sense of control. The person can take the med, they can look at the med, there's control aspect there. So patients, a lot of people really fear reducing anything related to it because, because they have a big question in their head. And that question is, what if the pain comes back? So the program in this study did not magically erase medication use, but it did shift behavior for a chunk of the patients. And the self efficacy was really the game changer. So the people who believed that they could handle their pain had a much lower likelihood of staying on meds. And it wasn't just baseline self efficacy. The patients whose self efficacy improved during the program also saw the biggest changes. And, and that's part of the cool part, self efficacy improvements, they reduce the absolute risk of continued medication use. And the effect is strongest in people already using medication. So that means we could do really great things by helping people feel more capable, by helping our patients feel they can control their symptoms by helping Our patients trust their body again and that's a real lever for reducing medication uses. The researchers didn't find that self efficacy interacted, quote unquote statistically with medication use at the odds level, but at the absolute risk level, it's a huge difference. And for you and I, that's what clinically matters. So there's a lot of people. Again, why, you know, how do we apply this? Well, one first, it's important to understand that many people are coming to you already using analgesics. So now you have the research showing that they're 10 times more likely to stay on them unless something shifts during the care that you're delivering. And improving self efficacy. Self efficacy is one of the most powerful tools you can use. What we do naturally, it promotes movement, it promotes recovery, expectations, active coping, behavior change, lean into those things, you are literally in the perfect position to boost self efficacy. There's probably not a better provider out there than yourself. Also, medication reduction isn't just about pain, it's about identity that's impactful. Many patients don't reduce meds because they don't believe they can. So when the care you deliver increases trust, when it increases confidence, safety, understanding, movement, comfort, patients will naturally shift away from the pills and meds and naturally towards active solutions. And this reinforces the guideline based care that you and I know, international WHO guidelines, they already emphasize exercise, education, activity, all, all of these things. And they caution heavily against medication used for chronic low back pain. This study continues to validate that. So help your patients and consider your systems and processes. Do they help people stay engaged? Do they help your patients have better outcomes? I think the better outcome is probably the easy part. But how are you really having conversations with them day in and day out that helps them understand they can trust their body and again overcome the that fear avoidance behavior. So this is important to bring up during your report of findings, during your daily visits, during your progress exams, and as always, you can use this type of information in your email marketing, your reactivation campaigns, your social media content, as well as with other healthcare providers. By positioning yourself as being aligned with the guidelines, position yourself as being a safe alternative to long term analgesics and really an ally in that reduction. So medication behavior is really sticky. That's the take home message. But it doesn't need to be permanent, but it's not gonna happen on its own. Meaning that people aren't just gonna stop taking them quite often on their own. They need reasons. Those reasons need to be active. And you're probably the best person in their life to have those active conversations with your patient. So I thought this study was great. A lot of just great clinical pearls, nooks and crannies of information could dive into. I'll drop a link down in the show notes so of course you can check it out at your own leisure. Also, big shout out to Chironeedle, new partner of the Evidence Based Chiropractor. If you're looking for dry needling chironeedle, they do a fantastic job. It is built around how we approach dry needling as chiropractors. I love that chironeedle.com, they will also hook you up with a discount by being a listener of this podcast. And thank you so much for tuning in. Thank you for being a chiropractor. If you've not left a rating or review, I'd love it if you would scroll on down, tap how many stars, leave a line of text that helps more and more people find out about this podcast. I hope you have a fantastic week in practice and I will talk to you soon.

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