Takeaways from the book, ‘The United States of Opioids: A Prescription for Liberating a Nation in Pain,’ and strategies to combat the opioid epidemic for DCs
Few are free from the anguish surrounding the opioid epidemic, including Harry Nelson, a nationally recognized health care legal expert and attorney with personal and professional experience that called him to write “The United States of Opioids: A Prescription for Liberating a Nation in Pain.” The book educates the public and medical providers about the issues, causes and solutions in the opioid crisis and outlines strategies to combat the opioid epidemic.
Reading the book and twice interviewing Nelson inspired this summary, which includes my opinions on how chiropractic is among the important parts of the opioid crisis solution.
The mechanism and crisis
Opium and its derivatives trick the body and mimic endorphins and dopamine, which in turn creates an intense wave of pleasure, slowing the respiratory system dangerously low. Over time, opium tolerance accompanies regular use, which requires more (and more) use to mimic the same intense pleasure. Users also experience oversensitivity to pain with elongated use.
The majority of pain-medicine-prescribing doctors are not current on best practices for treating pain and prescribing opioids. One report found only 20% of prescribing physicians have received “safe prescribing” training. Yet, 20-24 million Americans — one in sixteen — are estimated to have a substance-abuse disorder (SUD), 55-60% of whom are abusing opioids. Approximately 80 million additional Americans are at risk for a SUD. The cost associated with opioid abuse ranges from $500 billion to a trillion dollars.
Two-thirds of all drug-related death is via opioids, per the CDC. An estimated one million Americans will have died between 2000-25, a shocking toll exacerbated by the powerful opioid fentanyl and its successors, which can be a hundred times more potent than fentanyl.
Aggravating matters, physicians have a hard time saying no to patients wanting immediate relief. After all, nonmedication approaches — chiropractic, acupuncture and physical therapy — take longer than popping pills. Additionally, many insurers decline to cover, at least fully, non-pharmacologic options, which still are not considered “evidence-based,” despite much research supporting these non-medication approaches — and plenty more research pointing to opioid dangers.
This is where chiropractors can help with strategies to combat the opioid epidemic. Personal injury cases often result in severe injuries, with pain management starting at the chiropractor’s office. As first responders, chiropractors are called to refer patients for specialist evaluations (e.g., surgery, injections or medication), which is when SUDs can take root.
As Nelson opines, medical providers, including chiropractors, can help prevent SUDs by:
- Advocating for alternative, non-invasive pain treatments (e.g., chiropractic) to patients and medical peers.
- Understanding opioid abuse and addiction.
- Tagging and following up with patients in danger of developing SUDs.
- Spotting (and stopping referring to) physicians who over-prescribe.
The dark history of opioids
Opium goes back some 50,000 years, and evidence suggests it was present in Neanderthal times:
- By 1906, opium was regulated by the Pure Food and Drugs Act.
- It faced worldwide restrictions by 1914.
- The 1920s saw court decisions holding doctors strictly liable, causing reluctance to prescribe opioids for pain.
- More laws came forth in the 1960s and early 1970s, with the Drug Enforcement Agency formed in 1973.
- Responding to a wave of online prescriptions in 2008, then-President Bush signed the Online Pharmacy Consumer Protection Act, requiring in-person medical evaluations to prescribe controlled substances.
Since addiction was viewed as a moral issue, medical school did not sufficiently address pain and addiction. Doctors were confused on pain treatment standards of care, not because they were bad doctors, but because they were ill-prepared and therefore vulnerable to misinformation from Big Pharma.
In the 1980s, the prevailing belief was that opioid addiction was not a high risk. The subterfuge was led by Purdue Pharma, whose owners became one of America’s richest families: the Sacklers. Purdue brought OxyContin to the market in 1995; during that first year, evidence suggested that OxyContin was being abused. Purdue Pharma told its sales reps to lie and claim that the drug wasn’t addictive, all the while claiming competitors’ drugs were addictive.
Purdue Pharma even manufactured false statistics.
An FDA examiner in Purdue Pharma’s pocket approved a statement saying OxyContin was safer than rival products because of its delayed-absorption mechanism. Facing an investigation and criminal prosecution in the early 2000s, the company hired Rudy Giuliani to kill the lawsuit. In effect, that’s exactly what he did. The settlement paid by Purdue Pharma was a drop in the bucket.
Over the past two decades, the government and health care system have responded with strategies to combat the opioid epidemic and stopgap measures. They’ve cracked down on doctors, created more laws to restrict prescriptions, and made naloxones (medications used to block the effect of opioids, such as NARCAN® Nasal Spray) accessible from a pharmacist without prescription. But until chronic pain management and addiction treatment improve, opioid abuse will continue.
What chiropractors should know about addiction
As noted by Nelson, Americans are getting progressively less happy, which means we are often more susceptible to dark paths, which we often attempt to self-medicate through opioid use.
Aggravating matters, addiction treatment is an underdeveloped system. State licensing and operational rules governing treatment vary wildly, such as in California, where only voluntary certification is needed. Addiction treatment counseling remains an area of mere certification rather than a regulated, licensed profession with board oversight.
Many addiction-recovery programs (such as 12-step programs) are based upon abstinence, which can be a psychological deterrent to opioid addicts as it comes with a high rate of relapse. Treatment without support for sustained recovery leaves people vulnerable to relapse, particularly considering that drug use is only a symptom of deeper, underlying issues.
What might be interesting, though, is that areas with legalized cannabis experience reduced rates of opioid prescribing, abuse and accidental overdose deaths. Cannabinoid research is promising, with more evidence suggesting it reduces inflammation, which results in diminished pain, making it easier for patients to emotionally regulate themselves and sleep despite pain. That said, cannabis can be psychologically addictive, impair work and damage social relationships. It also lacks FDA oversight.
Chiropractors and strategies to combat the opioid epidemic
Chiropractors are often the first responders in pain management cases (at least in personal injury, which is my personal focus), with new patients starting their treatment journey at the chiropractor’s office.
When chiropractors have a deeper understanding of the opioid crisis, they are better able to educate patients about nonmedication interventions and the dangers of opioids. While chiropractic care might take longer than popping a pill or surgical interventions, it lowers addictive triggers.
When medication is required, chiropractors can help by understanding the seven “pillars” for correcting the nation’s opioid crisis, as outlined by Nelson:
- Join in outreach and education. Many patients are likely taking opioids now, without realizing it.
- Improve physician Before referring, ask prescribing doctors whether they have received training on safe prescribing. Flag physicians who never refer back to them, as this indicates that the doctors are uninterested in conservative pain management approaches.
- Support innovation to improve therapeutics and care, including numbing drugs (e.g., bupivacaine) and other “wearable” technologies for monitoring and flagging issues.
- Understand accidental overdose Make sure patients know that naloxones (to block the effect of opioids) are available from a pharmacist without a prescription.
- Support interdiction efforts to stop illegal sources of opioids, including fentanyl and more potent opioids being smuggled via online access through China.
- Support data and analytics to address health risks. A national database would go a long way toward gathering and sharing information about opioids.
- Support strengthening of and access to addiction treatment and recovery support. This includes greater insurance coverage and government pressure on insurers by enforcement, along with expanding telehealth and clarifying treatment standards.
In the end, we need a unifying strategy that: (1) lowers deaths; (2) manages treatment of pain better; and (3) provides effective treatment and ongoing support.
Chiropractors have a key role in strategies to combat the opioid epidemic in educating patients and the public in general; in directing those with issues to get the help they need; in educating their medical doctor peers to refer to them and others for non-invasive, longer-term treatment to lower the triggers and obtain pain relief; and in embracing their key role of problem spotting, education, and serving as caring and competent health care professionals.
We each can make a difference, but chiropractic can play a larger role than most.
MICHAEL COATES, ESQ, is an attorney and the founder of PIMadeEasy.com, which helps medical providers in personal injury matters. For more information on this topic, listen to Harry Nelson’s guest appearances on Michael Coates’s podcast, PI Power Hour, which you can listen to by emailing [email protected]