Chiropractic vs Physical Therapy vs Opioids | Podcast Ep. 334

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are back with the research and this is a study that analyzed physical therapy, chiropractic care and medication usage for people with chronic pain and it looked at the entire state of Rhode island for a multi year period. This study just came out this month. We're talking May 2022 and there are some great clinical pearls and take home messages that all of us should be in tune with as we communicate with people in our communities. We're going to dive into this and much more on today's episode. Before we get started, I'll say a few words about the smart chiropractor. Smart chiropractor can power your patient journey to provide you with more of your ideal new patients, better patient retention and more consistent reactivations without spending any money on advertising. You can lear what we mean by that, how we can help your practice. You can even schedule a demo over@thesmartchiropractor.com again that is thesmartchiropractor.com but on today's episode we're talking research. A study that came out in the Rhode Island Medical Journal in May 2022 and the title is Receipt of Physical Therapy and Chiropractic Care by Adults Diagnosed with Chronic pain. Analysis of 2016 through 2018 Rhode Island All Payer claims database. And this is a really, really fascinating study. Lot of great clinical pearls as I said at the top. If you are new to this podcast, you might not know. I grew up In Rhode Island, 0 to 18 years old. Then I went back, practiced as an associate for about a year and that's where I had my own private practice as well, up on the hill near Brown University in downtown Providence. So Rhode island is somewhere I'm very familiar with. It also is a fascinating place. It is smaller. The entire state is smaller than the county I live in today. So the state of Rhode Island Fitness, 30 miles wide, 60 miles tall, about a million people, that is the state of Rhode island and if you are geographically challenged, sits kind of under Massachusetts, to the east of Connecticut, up in the northeast. And this study took a look at their all payer claims database to see what was going on. What are people that experience chronic pain in the state of Rhode Island? What are they utilizing? And this was based upon claims data. So it was not subjective. It wasn't what people are reporting or a questionnaire. They were looking at the data and saying what are people billing for? What are the codes associated with that and what's going on. And there's some fascinating takeaways here, so let's dive in and see what's up. So we know chronic pain is a huge epidemic and between 10 to 30% of people in acute pain transition to chronic pain. And a lot of that variability comes down to what care they receive early on. If they receive movement based care, it's less likely that they're going to transition into chronic pain. If they receive medications, et cetera, it's more likely that they will transition to chronic pain. So very, very important. We also know that opioids are still a component of this, believe it or not. And we know that opioids are still sometimes prescribed to manage chronic pain, even though there's a complete lack of evidence to support their effectiveness. And, and there are high harms. This is something that is just still out there. I know it probably sounds old hats like gosh, I hear this time and time again, but it is important that we all are aware of this, that those individuals who are not coming into your practice for acute and chronic pain are probably getting bad care elsewhere. I hate to say it that way, hate to be so ardent about it, but, but the research has shown this time and time again there are some fantastic docs out there that have totally stopped prescribing opioids for spinal issues when there's not red flags. Kudos to those doctors. But there are still way, way, way too many that are reliant upon these medications. Even though the Hippocratic oath is doing no harm, even though there's no evidence at all for effectiveness, and there are ridiculously high harm rates. So despite the emerging evidence based guidelines, chronic pain remains a challenge in many primary care offices because of a reliance on opioid therapy, just habit, and in some cases insurance coverage restrictions for non pharmacological and complementary approaches. This is a big deal as well. And I know we've all dealt with this at times where the MMI maximum medical improvement. If you are not a cash based practice, you probably just winced when I said that. This is just the quirkiness and craziness that we experience as healthcare providers and that trickles down to the overall health of our community. Quite frankly, many insurance companies seem to be perfectly happy to allow medications to be prescribed even though they're ineffective, even though the dosages tend to become upped as people become sensitized to them. People take medications for pain for decades on end, yet every six visits they wanna see if the patient's plateaued with Their chiropractic care. It's insane because we know that in many cases chronic pain is more about management than it is about cure. We've seen that in the studies. Apparently you can manage it with medications that have diminishing returns over time. But even remaining stable with chiropractic care is a challenge from a payer perspective. So that's probably a conversation for a different day and a larger convers. But it's an important piece of this because there's just the brass tacks of those individuals that are reliant upon insurance coverage that are making decisions based upon that. And quite frankly, when they go into MD A do whoever it might be's practice that's gonna influence decision making to a certain degree. It's just the way it is. I hate to say it, but it is just the way it is. So this study was looking at the Rhode island all payer claims database. Now we. What is that? Well, it houses 80% of the state's population, 80% of the healthcare data. So it's pretty extensive. And they took a look at Rhode island residents over 19 years old, greater than or equal to 19 years old, who were diagnosed with chronic pain from January 2016 to December 2018. And they defined chronic pain based upon the diagnosis codes. They needed at least one or more of the diagnosis codes that were highly likely to indicate chronic pain antidotely. They put in the study, which I agree with. NSAID use is probably underreported in claims data because of the availability over the counter. And it's probably dramatically underreported. How many people are prescribed NSAIDs versus those individuals who walk into a pharmacy and pick up NSAIDs. You know, that's probably dramatically disproportionate. They were looking more in terms of opioids on this study, more so than NSAIDs. But this included about 300,000 unique Rhode Islanders, which is about a quarter of the state's total population. And here's some of what they found. One third of chronic pain patients received PT over that time period and 2/3, 66% received chiropractic care with some receiving both. So there is overwhelming, maybe not an overwhelming, but a majority. Two thirds of the individuals who had chronic pain in the state of Rhode island in the couple year period had received chiropractic care. That's a big thing, I think in the right direction that showcases that the utilization is there. We'll dive into the not so good news, but I think that's pretty good news. Overall, the mean age of the individuals in this sample size were 54 years old and 61% were female. A majority of people also had commercial insurance. So the overall prevalence of physical therapy use was 4.2% per month and about 7.2% for chiropractic care. And back, neck and limb related pain accounted for a majority of the use cases. Which makes sense. And here's how that split down. If we were looking at physical therapy monthly and we looked at back, neck and limb pain, that was 21%, 26% and 18%, we did the same thing for chiropractic and we said, okay, over the course of a month, what's the prevalence? Why are people coming in? 32% of people who sought chiropractic care had back pain, 43% had neck issues and 18% had limb pain. Chronic, of course, as this study sort of dictated. So take home message there. It was interesting to me to see that neck issues, chronic neck issues were beat neck, low back issues, excuse me. So we always think of low back as really that dominant force. Now in this study it was a smaller population still 300,000 people. Neck pain was by far. Whether somebody went to PT or whether they went to Cairo was by far the leader in terms of why they reported having chronic pain. So important to keep in mind. What's the take home message? There's getting out there and communicating. Neck, back and limb pain is probably pretty important because all three have high utilization for individuals that struggle with chronic pain. So you take a look at your messaging. I know low back is kind of a core tenant of a lot of what we do within chiropractic and our communication neck pain is as well. But don't sleep on it. There might be more people with chronic neck issues in your community than even low back issues. That's kind of that take home message. Now what was going on on the opioid front? Opioid prescribing amongst Rhode Islanders diagnosed with chronic pain decreased from 12% to 8% over that 2016 to 2018 period. So 2016, 12% of people with chronic pain in the state of Rhode island were receiving opioid medications. By December 2018, it was around 8%. That still is so high to me, I can't grasp it. The fact that in 2016 over 10% of people with chronic pain in an entire state were getting opioid prescriptions is insanity. And the fact that in 2018 it was still just a touch below 10%, absolute insanity to me. We also know that over the last two and a half years, pretty Much all gains on the opioid epidemic have gone out the window. And in almost every single study that I have seen to date, the opioid prescription usage, I guess you'd say, or how often it's prescribed is beyond what it was before we started to see those decreases. So between 2016 and 2018, that's really the height of the decreases. So they went from 12% to 8%. Still ridiculously high as far as I'm concerned. But we could estimate now, we don't know, but I'm gonna throw out there it could be up to 15% today. If Rhode island is the same as we've seen the swing in many other states, they probably are exceeding the levels of prescription for opioids from 2014, 2015, 2016. And this is something that I think we all need to take really take a step back, you know, and really analyze what's going on, people in your community. I just want to put it in perspective. Number one, this is something that medical organizations should really be taking a look. Some of these providers need to be held accountable. There are some great providers out there again that have stopped prescribing opioids for spine related issues in chronic or acute pain. And kudos to those providers again. But there are far too many providers out there that are still reliant in prescribing opioids. Even though it's guideline discordant, even though they've taken a Hippocratic oath, even though they know it results in addiction, even though there are hundreds of thousands of deaths and, and there is basically no evidence showing that they are effective at all with super high harm rates. So that's what's going on now. What does that mean to us? That means to us, this is why we need to communicate. Because if these patients are not being referred in from other healthcare providers, if you need help with that, head over to the evidence based chiropractor. But if they're not being referred in by other healthcare providers, they very well could be going down the road of receiving medications, eventually opioids and potentially surgical intervention if they don't hear from you. So how can they hear from you? One of two ways, pretty simple. One is they get referred in by another healthcare provider. That's the ideal. Number two, you're out there teaching and inviting consistently enough that people know who you are, what you do, and they're making that proactive choice to come in and to and receive care in your practice. But it's not going to happen accidentally. It's not going to happen on its own. And it's all of our responsibility to get out there and teach and invite consistently. So that is really for me, the take home message. So chiropractic care was more common than physical therapy amongst adults with chronic pain in Rhode island and monthly receipt of either treatment remained low. Again, monthly prevalence 4 and 7%. Second, the use of PT slightly increased compared to chiropractic. Chiropractic was pretty flat between 2016 and 2018, but PT actually increased a little bit and they found PT trended upwards whereas chiropractic use remained unchanged from 2016 to 2018. So clinical trials here's where this study I've just It blows my mind that this is written in this study. Clinical trials for the efficacy, effectiveness and safety of many non pharmacologic and complementary approaches to managed chronic pain exist, but are subject to methodological issues that contribute to mixed findings and variable interpretations of the robustness of the evidence notwithstanding, there appears to be a preponderance of positive trials versus negative trials. And a recent evidence suggests that non pharmacologic and complementary therapies confer small to moderate, usually short term benefits, mainly for chronic low back pain. So this is where these studies kind of blow my mind because they're like at the end of this study they're saying, well, you know, there's not that much evidence to support, even though all of the guidelines now say people should do that and even though there is no effectiveness of opioids and there's a high harm rate. So this is one of those studies where I love what they've put out and I'm not criticizing necessarily the researchers here. I know there's a certain way you have to write a study and they're correct. There's a lot more that can and should and will be discovered regarding what we do with complementary and alternative medicine, chiropractic care, spinal manipulation, et cetera. But when the alternative is 8 to 10%, maybe 15% of people are receiving opioid medications, that is insane to me how this is not just a clear open and shut case of we need systemic change. And I'll give massive props to the researchers that come out here and really say it. And I'm sure that some have. So what were the conclusions on this study? Quote, Although non pharmacologic options are regarded as a key component of guideline concordant chronic pain management, we found low and largely unchanged overall monthly rates of PT and chiropractic care use in Rhode island from 2016 to 2018. Opportunities to raise awareness about effective non pharmacological treatment for chronic pain. And practical ways to engage patients with such care should also be considered. No kidding. So what does that mean to us as chiropractors? I think it ties back. Are you getting out there and teaching and inviting consistently? Are you showcasing who you are and what you do to the people in your community and, and not or, and are you getting out there each and every month to a target list of healthcare providers in your community to generate incoming referrals? If you're not, there are people in your community that are going down what I call the professional road of indifference. That means they are probably receiving NSAIDs, they have a mechanical issue, the NSAIDs they become sensitized to, the issue remains, they get an mri, a disc issue is found and next thing you know they're down for injections, potential surgical intervention and or opioids if they do not want surgery. And the days of that need to stop. Not going to happen overnight and it's not going to happen due to any sort of large organization. We've seen the guidelines shift yet. It takes a long, long time for that to be implemented at a practical level by Dr. So what can we do? We can be proactive with our messaging, we can be proactive with our relationship building and we can be proactive with the information that we give our patients in our community. So the good news about this study are many people are utilizing chiropractic care. The bad news is they're probably not utilizing at the rate that they need to and there still is way too many opioids being prescribed. So let's get out there, let's communicate, let's have some fun in the process. Not all doom and gloom. Let's have some fun in the process. We're, we can really change people's lives with the care that we deliver. By showcasing movement is about healing and by helping people understand that many of their issues can be changed through movement, through lifestyle effects and through ultimately getting a little more exercise, eating a little bit better, keeping a positive mindset. These things make a huge difference in our ability to help people get and stay well. So as we wrap up today's episode, I want to encourage you to head over to pro.powerstep.com sample and, and pick up a pair, a free sample pair of orthotics. Power step orthotics are exactly the orthotics that my father uses. He's had chronic, speaking about chronic pain, he's had chronic low back pain, neuropathy issues for a long time and Power Step Orthotics have helped him tremendously. They are willing and able to give everybody who's a listener of the Evidence Based Chiropractor a free sample pair. Try them out for yourself. Pro.powerstep.com sample these were founded by a a podiatrist over 30 years ago. The quality is awesome. I have a pair just a few feet away from me right here in the Evidence Based Chiropractor Studio. I'll drop that link down in the show notes as well. Have a fantastic week in practice and I will talk to you soon.

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Sam.