The prescription of opioids in primary-care settings to manage acute and chronic, non-cancer pain is alarming. According to a recent report from Harvard Medical School, opioid misuse is now one of the most important health problems in the United States, rivalling smoking as a cause of death. The trend is similar in Canada, with the Public Health Agency of Canada recently reporting that close to 2,500 Canadians died from apparent opioid-related overdoes last year.
The increased use of opioids is being driven by both their use as a first-line treatment for chronic pain, commonly mechanical back pain, and the lack of funded health services for non-pharmacological, conservative approaches, according to a study published earlier this year in the Annals of Internal Medicine.
In other words, opioids have become quick solutions for a growing number of patients with chronic back pain who do not know how or where to turn to get help beyond pain medications.
Successful treatment of back pain is complicated and often requires a collaborative, clinical approach. The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain, developed by the Michael G. DeGroote National Pain Centre at McMaster University, recommends the use of non-opioid medications and non-pharmacological, conservative therapy, rather than a trial of opioids.
These new guidelines highlight that effective solutions must include reducing the pressure to prescribe by prioritizing alternative approaches to pain management, such as multidisciplinary rehabilitation, spinal manipulation, massage therapy, acupuncture, tai chi, mindfulness-based stress reduction and exercise.
Care models that have chiropractors and physiotherapists collaborating with family doctors are leading the way. These include Inter-professional Spine Assessment and Education Clinics (ISAEC) which are funded by the Government of Ontario. Patients who enter the ISAEC program by referral from their family doctor receive rapid back-pain assessment by chiropractors and advanced-practice physiotherapists who have undergone rigorous training in advanced spine assessment with spine surgeons.
These programs have shown promise in managing acute and chronic musculoskeletal pain and reducing the pressure to prescribe opioids. The next challenge will be spreading the word. In a 2016 white paper titled A Better Approach to Pain Management: Responding to Canada's Opioid Crisis, the Canadian Chiropractic Association (CCA) writes that, "while there is a growing consensus about the importance of prioritizing evidence-based alternatives to opioids as a first-line treatment for chronic non-cancer pain, the key challenge is increasing awareness and better integrating these alternatives for Canadians struggling with chronic pain."
Chronic-pain sufferers need a well-crafted clinical strategy. I coach patients to think of their team of health professionals as their own personal senior management team. Working with a common purpose to support your health and performance requires effective communication and a team of professionals open to collaboration.
Non-cancer, chronic-pain sufferers are encouraged to consider the following questions when discussing the management of their health with their primary care practitioner(s).
Would a trial of evidence-based, conservative therapy including chiropractic care and physical therapy help in the management of my pain?
Adding manual therapy such as spinal manipulation to standard medical care has been clinically shown to be a viable, non-invasive and evidence-based approach to managing musculoskeletal-related pain and dysfunction.
Is the medication I am taking an opioid?
If so, is there an alternative that could be tried first?
Are there any non-opioid pain relievers I could take instead?
Some prescription, non-steroidal anti-inflammatory drugs (NSAIDs) such as celecoxib (Celebrex) and diclofenac (Voltaren) may present some side effects in comparison to over-the-counter NSAIDs, but they will not lead to dependence or addiction.
Is this safe to take with my other medications?
Be sure to review with your doctor the full list of prescribed and over-the-counter medications you are taking.
Is this the lowest dose possible?
It is important not to take a higher dose than you need for pain relief. Start with a small dose and ask your doctor to increase it if necessary.
Dwight Chapin, B.Sc(H)., D.C., is the clinic director of High Point Wellness Centre in Mississauga, team chiropractor for the CFL's Toronto Argonauts and on-site clinician for employees of The Globe and Mail. Follow him on Twitter @HighPtWellness.