How Primary Care Physicians Fuel the Chronic Pain Epidemic | Podcast Ep. 297

Foreign welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode we are going to highlight one of the most important papers that I have seen released in quite some time. Yes, that is a, that is a big statement to make. But I think you'll agree with me. This paper is all about risk factors associated with transition from acute to chronic low back pain and in US patients seeking primary care. This paper really highlights a lot of the challenges out there and knowing about it then enables you to have positive conversations as far as how we can move the ball in the right direction. So we're going to highlight all the facts and findings. There are some great stats, some great takeaways and much more on today's episode. Before we get started, we had over 15,000 leads come in to our smart chiropractors last month. And when I say leads, I don't mean people that you have to track down, people that are, you know, you know that what I'm talking about. These are individuals who called the practice click to the website or gut directions for smart chiropractor practices. We do that through Google my business auto posting, which is just one sliver of what we do to help you power your patient's journey from potential patient through being an active patient and then having a nice retention loop on the back end. If you want to check out more about that, then head over to the smartchiropractor.com demo thesmartchiropractor.com demo hop on with our team, let's have a conversation and see if the smart chiropractor is right for your practice. We're getting down to almost quarter four of this year, so head over to smartchiropractor.com demo and check it out. But as I said at the top today's episode, we're talking research. This was a JAMA Open Network paper that came out and it's all about health policy, which is a very interesting way to put it. And this title was Risk Factors Associated with Transition from Acute to Chronic Low back pain in U.S. patients CD seeking primary care. The reason I kind of half joke about saying health policy is we historically know that primary care physicians are dramatically not congruent with the current guidelines relating to musculoskeletal care. They were. Quite frankly, I think all of us as chiropractors would be full each and every day and we are not. But this paper starts to highlight a lot of the truth about what's going on, the stats behind it, which again Enable to power your conversations and about what's going on in and around your practice. So why is this such a big deal? Well, it's estimated that 13% of adults have chronic low back pain and 1/3 experience moderate to high impact chronic pain. That's powerful. We're looking at 330 million people in the United States. You break down the, I mean we're talking a lot of people. 13% of people with chronic low back pain, I've heard up to 30% have chronic pain and, and 13% in total have chronic low back pain. So treatment of low back pain and spine related disorders is the most expensive medical problem out there. The most expensive. Think about all the other things out there that are high technology, that require intensive care. And to think about the fact that even with all of that low back pain is the most expensive medical problem showcases why this is such a big deal. And a lot of this starts with bad information, quite frankly, and poor patient routing at the primary care level. We've been talking about this with the evidence based chiropractor for practically a decade, helping docs build relationships with other healthcare providers because we know it's such a big impact point not only for your practice, building and growing your practice by building relationships, but also man, when people get bad advice, and this is where this paper's gonna drive to, when people get bad advice, bad referrals, over imaged, over treated early on, this leads to super expense and it pushes people literally from acute pain to chronic pain. And chronic pain is of course, as you can imagine, more difficult to break. By the time somebody goes from acute to chronic, they now have what I'm just gonna refer to generally as habits involved. They have mindset involved, there's a psychological component, there's sensitization going on, there's pain threshold levels that have been reset, there's biochemical marker changes in the brain that, that occur and it doesn't happen on the 90th day just like that. But this is the transition from acute to chronic pain. And being able to break that and not let somebody get to chronic pain is one of the most important things I think all of us can do as chiropractors. Yes, it's about quality of life, being a chiropractor. Yes, it's about performance. But man, at the base level, imagine if we could help even half of these individuals not go to chronic pain. I think it'd be just a world of difference in our world, in our lives, and certainly it would affect tens of millions of people. So in this study, patients were considered to have chronic low back pain. If they had pain for more than three months and they experienced pain at least half of the days in the past six months. So pretty standard as far as how they were classifying that. And they basically looked and they said, okay, what are the guideline concordant they used? That's the terminology they use, guideline, concordant type things that can happen in a primary care practice. And what are the non concordant things? And any prescriptions that included opioids were considered non concordant. Duh. I mean, we have seen a, just. It's terrible and sad, but in the last year we have seen a dramatic bounce back. All of those gains that were taken in terms of the opioid epidemic over the last four years totally wiped out. Last year there were more opioid deaths than I think ever before. And it went up, I believe something like 30 to 50% between two years ago and last year. And that's a problem. We're gonna be talking about it a lot more after I think we get out of the current health issues going on worldwide. But it's something to keep your eye on. The other non concordant things that they discussed were diagnostic imaging, including lumbar radiography, you know, MRIs, things like that. Also a medical subspecialty referral, such as referrals to surgical specialists, orthopedists, neurologists, neurosurgeons, pain specialists, physiatrists. Again, when somebody comes in with acute pain, they should not be getting opioids. You know, acute spinal pain specifically, they should not be getting opioids. They should not at first glance get an MRI or a CT scan. They should not be sent to a physiatrist, an orthopedist, a neurologist, a neurosurgeon, a pain specialist. It's crazy. And I think all of us know that that's happening at scale. But let's break down some of the stats because I think even if you're like, man, I know that kind of stuff is still happening, these stats are going to surprise you. They found 30% of patients received prescriptions for non recommended medications. That's insanity. You know, 30%. You had basically a one in three chance. If you have acute low back pain or chronic low back pain for that matter. If you have low back pain and you go into a primary care physician, there's literally practically a 1 in 3 chance that you're going to walk out with an opioid prescription. That's unacceptable. And I don't Think there's any question at this point in time, Healthcare organizations need to get tough on this stuff. The fact that that can happen and there's no repercussions is, you know, it is an embarrassment, quite frankly. So 30%, but that's the facts and we need to know it. 25% received a CT or an MRI or they received imaging of some sort, radiography or CT or an MRI. So 25% got imaging and 6% were referred to a medical specialist within 21 days of that index visit, which is what they referred to as that first visit. That's crazy. 30% of people walked out with an opioid, 25% got an MRI and X ray or CT. 6% were referred to a medical specialist, with 62% of those being surgeons within 21 days of that first visit. That's what's going on out there. And the overall unadjusted acute to chronic low back pain transition rate at six months, not surprisingly, was 32%. So these are big, big problems that are happening, quite frankly, every day. Look out your window right now. If there's a primary care doctor, this was happening in their practice. So understanding that is critical to be able to find, okay, how do I bridge that gap? How can I have a proactive conversation with these people and also with my patients? Because again, a patient that we've all seen, this patient comes into you, they might be seeing you and somebody else, right? It's very common. It's more common than uncommon patients seeing multiple care providers. They might see their primary care doctor and they're coming to see you. And quite frankly, all of us have had this happen. Somebody leaves our practice based on the advice of a primary care physician. Now when we see this kind of stuff's going on, it's crazy town, but it's what is actually happening. So having proactive conversations with your patients around what they might hear in their primary care office, what the research out there says and the best plan of action. Critically important, you have to build that no trust and like factor. So these researchers discovered and found, not surprisingly, exposure to non concordant care was associated with increased odds of developing chronic low back pain. And developing chronic low back pain was over two times higher when somebody was exposed to one, two or three non concurrent processes in care. So not surprising, you were twice as likely to become a chronic pain patient when you had non concordant care, when you were referred too early, when you were imaged too early, certainly when you got opioids, duh, no surprise. But these are the Facts, and it's stuff that we need to take as conservative care providers, as chiropractors, as advocates for the patients. Super serious. The researchers also found, quote, these results indicate that the transition from acute to chronic low back pain is much greater than historically appreciated. Yeah, no kidding. There's a lot of people that are ending up in chronic pain because they're getting bad advice early on. They also say, quote, however, it should be noted that more than 60% of the 1666 patients who developed chronic low back pain at six months were in the low risk and medium risk groups. This is something I didn't touch on earlier and is even more impactful. They basically stratified people coming in with the pain. They said, okay, is this somebody that's low risk to become a chronic pain person? Is this somebody as medium risk to develop chronic pain, or is it somebody that's high risk? And they're saying even on those low and medium risk, 60% of those people, you know, developed chronic pain over time. So this is a cycle that absolutely needs to be broken. They found that 48% of people that visited primary care had at least one discordant process of care within three weeks. So within three weeks you have a one in two shot of either getting an opioid, getting advanced imaging, which we know leads to increased surgical intervention, or being referred to a neurologist, a surgeon. One out of every two people had one of those things occurring. This stuff needs to change. These rates of non concordant processes of care are similar to those reported in a claims analysis from 2.5 million individuals newly diagnosed with low back pain. So why is this happening? Well, they throw out a couple reasons, I'll say excuses. One of those is poor implementation of training within primary care physicians, and that basically for medical students, residents, general practitioners, musculoskeletal medicine, and the training associated with it is suboptimal. Now, I don't think it takes a PhD to really be able to say, hey, let me check out the guidelines. These three things are things I shouldn't be doing. Referrals to conservative care providers are something I should be doing. I don't know how much training it takes to really get that across, but clearly there still is a huge opportunity. As much as this is a sad story for a lot of patients going through these challenges, I also think you should look at the bright side and say, man, talk about a great opportunity in your business, in your practice, in your community, to help people overcome this, to save people from those challenges and to help more people Stay well and build and grow your practice in the process. It is a win, win, win for everybody. But we all need to take the bull by the horns and get out there and start having those conversations. Whether you're doing it with a program like the Smart chiropractor, where we're going to power your emails, power your social media, power your video content to make sure you're out there in the public getting these messages out, whether you're going to do the evidence based chiropractor, because you say, man, I want to go directly to these primary care physicians, these other healthcare providers and build referral relationships. I don't care which one you choose, many people choose both, but you got to do one. You know, ignorance is not an answer. You can't just put your hands over yours and say, well, that's nice. I'm just going to do my little bit here and maybe go to my breakfast group and that's it. This is a real problem. One out of two people are getting non concordant care. They tons, AKA tens of millions of people are ending up in chronic pain. It's something that needs to stop, but it's not going to happen on its own. It's going to take each and every one of us to take proactive steps each and every day in order to change things. So the conclusions to the researchers in this study, they found, the conclusion was, quote, early exposure to guideline non concordant care was significantly and independently associated with the transition to chronic low back pain after accounting for patient demographic and clinical characteristics such as obesity, smoking, baseline disability and psychological comorbidities. These findings suggest that an emphasis should be placed on discovering strategies to successfully implement guideline concordant care in the primary care setting to reduce the development of chronic low back pain. That just about says it all. And that kind of recaps to what we were talking about. What are you going to do each and every day? What are you going to do today to get out there to and to really start changing the dynamic in your community? Because I think about this in terms of when I was at orthopedic groups, et cetera, being able to direct people out of surgery and into conservative care providers. That's powerful. Those are lives changed and lives saved again. I'll bring up a neurosurgeon that I worked with that I highly respect. I think was actually a great surgeon and he told me, quite frankly, when I do surgery there is on the spine one of the 33% chance somebody gets better, 33% chance they're about the same afterward, 33% chance that they're worse. That's the truth and the facts out there. Now I guess if I told you or asked you and I do this for every evidence based Chiropractor member when I do their implementation call, I say what percentage of your patients are happy satisfied with their care and inevitably the answer is 80%. The odds are in our favor. The guidelines support what we do, but the practical application isn't there yet at a boots on the ground level. So get out there, build the relationships. Use the tools available to you. The smart chiropractor, the evidence based chiropractor. Use them, get out there and save people in your community from going down a road that they don't need to go down. Now as we close up today's episode, I want to encourage you if you are taking a vacation, if you are going to do CE anytime soon, or if you have an unexpected injury, maternity, paternity, whatever it might be. If you need to be out of your practice, visit chiromatchmakers.com check out our coverage team. We have tons of coverage doctors available that we vet. We go through everything. They're awesome. Throughout the domestic United States, if you need to be out of your practice, you do not need to close your doors. Don't lose that revenue. Don't break up the patient care. Utilize a great coverage doc. Utilize us@chiromatchmakers.com, i'll drop that link down in the show notes as well. If you have any questions, hit me up. Jeff the evidencebasedchiropractor.com and if you have not left this podcast a rating or review on itunes, I'm going to ask you to do so. I received an incredibly awesome review just within the last week that literally kind of made me stop and pause for a minute. So I check all those reviews out. It would mean the world to me if you would just take a moment out of your day. If you like this podcast, if you listen each and every week to head on over, leave a rating or a review that helps more people. Find out about the podcast and tune in. I hope you have an awesome week in practice and I will talk to you soon.

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