From pills to adjustments: Empowering patients to reduce Gabapentin use | Podcast Ep. 398

Foreign hello and welcome to the Evidence Based Chiropractor. I am your host Dr. Jeff Langme. This week we are back with more research. A brand new study that will be talked about for years to come. It is all about chiropractic adjustments and gabapentin use in adults with low back pain is a brand new study. We are going to highlight the take home messages that you need to be aware of and also again what I believe are the important points that will be discussed for years to come based on this study. It is brand new, hot off the press and it is a good one. Before we get started, I want to say a few words about the smart chiropractor. If you would like to pilot patients back into your practice. I'm talking about reactivations. You need to check out patient pilot by the smart chiropractor. You can schedule a demo right now@the smartchiropractor.com I'll drop a link down below. We work with over 350 docs around the world and we generate reactivations. If you have an email list that you are not maximizing, we want to help you maximize it. That's missed opportunity for your practice every single day that you're not doing something with it. So if you want to see how we can help, let's find out. Head over to the smartchiropractor.com, schedule a demo with our team. We would love to chat with you but as I said at the top, today's episode we're talking research Brand new study BMJ open. I'm gonna drop a link down in the show notes the official title is association between Chiropractic Spinal Manipulation and Gabapentin Prescription in Adults with Radicular Low Back Pain. A retrospective cohort study utilizing US Data. Why is this such a big deal? Well, it is a big deal because low back and neck pain account for the leading cause of medical expenditure in the United States. Yes, you heard that correctly. Of all other things, when you take low back lumbar spine and neck cervical spine issues, combine them, it is more money spent on that each and every year in the United States than any other medical expenditure that there is. Additionally, to compound that the highest prevalence of low back pain in the world happens in the United States. This is a huge, huge, huge deal as we highlight week in and week out on this podcast. So in specifically with this study they were looking at radicular low back pain and radicular low back pain involves a nerve root issue and is considered Neuropathic by definition. And of course it has radiating symptoms into lower extremity. Most of the time those symptoms are ipsilateral or unilateral. They're on the side of the nerve root issue. Now, we're what can compress a nerve? A host of different things, but generally speaking, you'll get disc, bone and ligament. Those are the three compressive items. Yes, there can be a fluid collection time to time, but the big three are disc, bone and ligament. Disc herniations, bulges, etc. Ligament hypertrophy, specifically relative to ligamentum flavum, that's more central, but you can get issues with that. It could go out and create a radicular symptom on an ipsilateral unilateral side. Additionally, we see bones, so osteophytes that are growing bone spurs can certainly cause compression in those foraminal canals. Now, non radicular low back pain can happen due to a variety of things. It can also be discogenic, but it could be myofascial. It's not the disc pressing on the nerve in that case, of course, it's the disc itself. So discogenic myofascial, sacroiliac facet joints, z joints, zygopophyseal joints, however you want to define those, those can create non radicular low back pain. And of course that does not radiate to the lower limb by the fact that it's non radicular. That is considered usually nociceptive pain as opposed to neuropathic pain. So those are the differences there as we set the stage for this study. Now, gabapentin, if you've been in practice more than one day, you've probably seen patients come into your practice that have been prescribed gabapentin for pain. Well, what is gabapentin? Gabapentin is actually an anticonvulsant, antiepileptic medication. That's what it's designed for. It's used as a first line treatment though for a couple different neuropathic pain conditions, including some neuralgias and diabetic neuropathies. That's where the overlap. So gabapentin may sometimes, occasionally it does provide some relief for neuropathic pain. How does it do this? It binds to the voltage gated calcium channels and then it inhibits ectopic nerve discharges. So that's how it works at a cellular or nerve level. Now, considering this mechanism, gabapentin, of course then is used off label. Is it used off label for spine pain? It is Used off label for spine pain. Let's make this super, super clear. To treat neuropathic symptoms in specifically radicular low back pain. So there's a million ways I could go with this right now, but if you believe gabapentin is prescribed on label for spine related conditions, you are sadly mistaken. Even though this is prescribed literally millions of times per year, that is a problem. Do you think that most people that are taking gabapentin know that that's the case? I can guarantee you basically none of them do. Now, gabapentin has been supported by the FDA for approval for neuropathic pain conditions since 1993. If you think that's a stamp of approval, uh, maybe we should have a whole different podcast on that. But this is despite the fact that Systematic reviews in 2018 and 2022 demonstrated clear evidence for its lack of effectiveness treating radicular low back pain. So there's a host of issues here. Number one, how is it approved? And now it's used off label. And now there is systematic reviews throughout multiple years showcasing a lack of effectiveness. Yet. Yet it's still used for the condition. And there's no teeth that people are doing it. That is a huge, huge issue for me and I believe it is probably for you too, as a listener. So there are several clinical practice guidelines out there that of course, as you can imagine, do the right thing and do not recommend gabapentin for the treatment of low back pain. Including American family physician. They came out with that statement and position in 2017. Yet how many family physicians are prescribing this way? Way too many. So what has gabapentin been described as a marker for? It's a marker for low value care and medical overuse. That is directly taken from the literature right here. So this medication has a host of issues. It should not be used. It is used all the time, every single day. That's a problem. We're gonna get into the numbers. But being empowered with this information is the first step towards understanding just how widespread of a challenge this really raises. Really is. So in contrast to clinical guidelines. Excuse me. Gabapentin continues to commonly be prescribed for low back pain. And there was a cross sectional study. They looked at about a quarter million outpatient visits in the United states over a five year period, 2011 to 2015, and found that 99% of gabapentin prescriptions were for off label indications. That's insane. And the most common were degenerative spinal disorders, other back problems. And that accounted for 27%, those two things, 27% of those total prescriptions. And there were increasing rates of prescription of gabapentin and concomitant opioid and gabapentin prescriptions between 2006 and 2018. So these things kept and continued to grow year over year. So the more that gabapentin was prescribed, the more opioids were prescribed, even though as we just touched on not recommended by clinical practice guidelines and it is utilized off label. And there are a host of challenges that come with recommending this medication. So on the flip side, and people don't bat an eye over this to take it number one and the providers in general don't bat an eye to prescribe it yet on the other side of this coin, you know, is chiropractic spinal manipulation or adjustments. Chiropractic spinal manipulative therapy is supported as stated in the literature, is supported by systematic reviews and recommended by clinical practice guidelines for the treatment of low back pain and radicular low back pain. And I say this because if you've ever been over to my YouTube channel, the evidence based chiropractor, as I like to say, don't look at the comments when your kids are around. Oh my gosh, talk about an avalanche of negativity around how unscientific chiropractic is yet and specifically related to low back pain most of the time yet the studies and the evidence are the complete opposite of what the public believes. Now why is that the case? In my opinion, part of that is because people go into the medical doctors and being given the worst care imaginable off label non guideline concordant care so they believe that that's the correct thing and there's fear around getting an adjustment movement based care, absolutely nuts. But it's the world we live in and you need to be aware of it. So you know how to position yourself in your community and through the content you put out, through the emails you send, through the communication you have knee to knee, heart to heart with a patient. You need to have a clear understanding of where they're coming from because most of the time they're not coming at everything from the same place you are. With an understanding of their body certainly, but also just from the paradigm of health is is so different that sometimes we as chiropractors, I feel like we've lived this way for so long. We've been around chiropractors in chiropractic school. We live a chiropractic lifestyle, meaning natural healthcare movement, really trying to take care of Ourselves in a way that, quite frankly, the longer we do it, we don't realize how far away that is from many of the common ways to take care of health. Many of the common ways people believe that their body works. And that starts to become a communication challenge over time. And it's a communication challenge we need to be aware of. And papers like this really highlight how big of an issue that is. So in this study, they looked at individuals between 18 and 48 years old. And a couple interesting points here. Neuropathic pain, as they highlighted here, is more common in people with lumbar disc herniations compared to stenosis, scoliosis or spondylolisthesis. So the age bracket of adults under 50 was selected for radicular low back pain because it's more likely to be from a disc herniation sub 50 years old compared to above 50 years old. You're looking at stenosis really contributing most often with ligament to flavum hypertrophy most commonly for radicular low back pain. So they took people under 50 due to the fact that that would be most commonly associated with a disc herniation or a disc issue. So broke it down into two cohorts. One received chiropractic spinal manipulative therapy, the other received, quote, unquote, usual medical care. And There was about 1,600 patients in each cohort. So gabapentin prescription was less frequent in the chiropractic cohort over a one year follow up after radicular low back pain diagnosis, both before and after matching. Now, after matching, 4.6% of patients in the chiropractic group and 8.3% of patients in the usual medical care group had received a gabapentin prescription. So in the chiropractic group, it was literally cut in about half. That is a big, big, big, big deal. And the importance of this are these are like real world findings. So this is real world. It is looking back at what occurred when people visited a chiropractor, what occurred when people received usual medical care. And over a one year period, which is a pretty good amount of time. So in previous studies, such as 2018, about 20% of U.S. adults who visited a medical doctor for low back pain recommended gabapentin. In this study, it stood at about 8%. Does that mean things are getting better or was it just random? It was difficult to ascertain via this study alone, but it's encouraging that it was less. Only 8% of people were recommended gabapentin in the medical care group. As opposed to 20, that's for sure. But it still showcased those who sought chiropractic care had that cut in half. Now why is that the case? Well, number one, obviously because chiropractors don't prescribe medication. They're not going to get the prescription from the chiropractor. But there goes, there's many more levels to this, including the fact that it's an indication that people had relief because they weren't seeking medication. It's an indication that they were given the information to make a great decision. So maybe they made a difference. So there's a lot that goes into this that is really, really important. And if you want to chop down literally by half the amount of gabapentin that's given out in your community for low back pain, you got to take care of more people. That's what it comes down to. Because there's no shortage. There is no shortage, as we highlighted early on, of individuals in your community right now, right now struggling and suffering from low back pain. So are you getting out there in the best manner possible? Are you doing everything you can to communicate with them? Because if not, many of them are going to go towards over twice as many as if they came to you. If they don't come to you, there's two times more likely to go receive an off label medication that very often results in a cascade of additional medications and additional interventions from which there are big time epidemics. We're talking opioid epidemic, we're talking post surgical complications, 20% complication rate, typically in a surgical setting. These are really, really big deals. So in this study they highlighted that their findings add to a growing evidence that the receipt of chiropractic manipulative therapy early in care for new low back pain and radicular low back pain could lead to greater concordance with these guidelines with respect to medication prescribing practices. How ironic that visiting a chiropractor makes the system more concordant with the recommendations that don't require medications. You'd think the individuals that were prescribing the medications would take the onus on their back to say this is not the right thing to do. I need to, should be and can be better and I'm going to evaluate what the best options are. It doesn't seem like that's the case. So we from the outside in are making an impact on that with the care that we deliver. That is how powerful it is that, that is why this study is so, so important. They also highlighted that their findings are consistent with other authors recommendations that patients with low back pain and radicular low back pain should initiate treatment with non pharmacological providers such as chiropractors straight out of the literature. So this large retrospective cohort study found that adults receiving chiropractic for a new diagnosis of radicular low back pain had signed significantly reduced odds of receiving a gabapentin prescription over a one year follow up period compared to those who received medical care and these findings are consistent with influence on a patient's care pathway towards avoiding medication use. That is a big deal. That is why this study will be talked about for years to come and I have a feeling there will be numerous follow ups, secondary analysis and much more regarding the findings in this study. And I welcome it each and every step of the way. So I hope you're able to take up some great information and knowledge again. I'll drop this link down in the show Notes and I loved it. And I hope you loved it too. Before we wrap up today's episode, I want to say a few words about powerstep Orthotics. 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We can take the pain out of hiring so you can hire better, faster, cheaper and easier. And if you do it now, you can be onboarding those new individuals with while everybody else is still looking for that new individual to really accelerate. Fourth quarter is where most businesses, including most chiropractic practices do really well. If you want to accelerate that now is the time to get ahead and ensure that you have the team in place to hit your goals, visit chiromatchmakers.com Other than that, if you have not left us a rating or review, I would love it if you would scroll down and leave us a rating or review that helps. More Docs Find out about this podcast thank you for being awesome. Thank you for being a chiropractor. Have an awesome week in practice and I will talk to you soon.

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