Articles by JCS

National Scandal

                                                                                                   

Word count: 2488

A National Scandal

By

JC Smith, MA, DC

America has a drug pandemic unlike any other country in the world, but the most dangerous drugs are not illegal street drugs such as cocaine, methamphetamine or marijuana. Today prescription opioid painkiller medications have caused more addictions, overdoses, deaths, broken homes and destroyed lives than any other type of drug this country has ever experienced.

Moreover, millions of families are left destroyed as President Obama said at a 2015 panel discussion on opioid drug abuse. “This crisis is taking lives; it's destroying families and shattering communities all across the country. That's the thing about substance abuse; it doesn't discriminate. It touches everybody.”[1]

According to new data published in CDC’s Morbidity and Mortality Weekly Report,[2] there were over 47,000 overdose deaths reported in 2014, which equates to 128 deaths each day.

The CDC reported 61% of all overdose deaths were from prescription opioids and heroin; a record 28,647 in 2014 or 78 people a day.[3] This death figure is up from the 2012 CDC report, “Opioid Painkiller Prescribing,” that analyzed data and found 44 people died daily that year from an overdose of prescription painkillers in the U.S.[4],[5]

Not only do 78 people die daily from opioids in the U.S., but it also is estimated that 4 out of 5 heroin users stared out abusing opioid pain relievers.[6]  This “invisible addiction” of the non-medical use of opioid painkillers by those who have become addicted costs health insurers up to $72.5 billion annually in direct health care expenditures.[7]

Let’s put this into perspective: If Islamic terrorists were killing 78 Americans daily in our country, there would be a huge public uproar, Congress would be calling for military action, and the media would be swarming for information about who’s to blame.

However, because we cannot identify a specific individual to blame but rather the entire medical profession and Big Pharma as an underlying causes of the problem, little is said or done by the powers that be including the press, save for occasional documentaries.

Considering the lobbying monies paid by the medical-industrial complex to congressmen and the advertising dollars paid to the media by pharmaceutical companies, this embargo of criticism should be expected just as we witnessed during the Obamacare healthcare debate when Congress failed to call the medical cartel to hearings to explain why American healthcare was so ineffective and expensive.

According to author Steven Brill in his TIME magazine article, “What I Learned from My $190,000 Surgery”, the medical-industrial complex spends four times as much on lobbying as the No. 2 Beltway spender, the much-feared military-industrial complex.[8] Just as congressmen and the media have learned not to question the excessive military budget or egregious behavior of Wall Street bankers, congressmen have ignored the damage done by Big Pharma.

One issue that cannot be ignored is the huge money spent on Capitol Hill. According to OpenSecrets.org, the annual lobbying on health legislative issues in 2015 was $381,223,403 of which Big Pharma alone spent $178,863,490.[9] The total spent in 2015 was down from $556,002,269 at the height of the Obamacare debate. The massive lobbying cost is inconsequential upon the realization that the top ten Pharma companies in 2013 earned over $441 billion in sales.[10]

The total contributions by health professionals to federal candidates and parties amounted to $70,377,772 for the election cycle ending in 2014. The AMA alone contributed $19,650,000 in 2014. In comparison, all the chiropractic contributions amounted to a paltry $527,832.[11]

Indeed, it appears self-interest groups with economic agendas are in control of this dire situation as long as there are billions of dollars to be made by all parties — including the AMA, Big Pharma and congressmen. Obviously there is too much money in American healthcare to let 78 deaths a day change how Big Pharma and the AMA conduct business. Of course, any lawsuits arising from bad drugs are merely the cost of doing business. We have witnessed this same thought process in the auto industry; deaths are the cost of doing business.

Promiscuous Prescribers

In 2014, the CDC revealed in its shocking study, “Opioid Painkiller Prescribing”,[12] that MDs prescribed 259 million prescriptions for opioids, equivalent to one for every American adult.[13]

CDC Director Tom Frieden, MD, MPH, admitted that physicians had essentially supplanted street corner drug pushers as the most important suppliers of illicit narcotics.[14] Ironically, by using an MD instead of a street pusher, this drug deal is perfectly legal and paid by health insurance.

Physicians are by far the most important sources of opioid pain relievers. However, many of those who overdosed were not originally given prescriptions. They borrowed or stole them from the original recipient of the prescription as teenagers often steal from the “medicine chest” in the family bathroom. In other words, quite a number of opioid ODs stem form illegal opioid diversion rather than perfectly legal transactions.

 “The increasing number of deaths from opioid overdose is alarming,” Dr. Frieden said. “The opioid epidemic is devastating American families and communities. To curb these trends and save lives, we must help prevent addiction and provide support and treatment to those who suffer from opioid use disorders.” [15]

In fact, this opioid epidemic is fueled more by well-meaning doctors than by heroin dealers. More than six out of 10 drug overdose deaths in 2014 involved opioids, including opioid pain relievers and heroin.[16]

Previously, the pandemic of opioid poisoning was blamed upon the egregious “pill mills” and pain management centers, but considering there are many more primary care physicians, their total outweighed these specialists.

The earlier studies suggest potentially aberrant behavior among those extreme outlier prescribers, implying the remaining majority do not contribute much to the problem. “Now we know this is not the case” according to Stanford researcher,  Jonathan Chen, MD, PhD and instructor of medicine and Stanford Health Policy VA Medical Informatics Fellow.[17]

“The bulk of opioid prescriptions are distributed by the large population of general practitioners,” said Dr. Chen. Opioid prescriptions are dominated by general practitioners — the family doctors, internists, nurse practitioners and physician assistants that most patients see for common problems — and not by a small cadre of high volume "pill mill" prescribers once thought to be fueling this epidemic. [18]

By sheer volume, however, there are so many more general practitioners that they dominated the total quantity of prescriptions. The specialties that prescribed the most Schedule II opioids in 2013 were family practice (15.3 million prescriptions), internal medicine (12.8 million), nurse practitioner (4.1 million) and physician assistant (3.1 million prescriptions).  

Researchers found that the top 10 percent of opioid prescribers account for 57 percent of opioid prescriptions. They found that opioid prescriptions per prescriber were concentrated among specialty services for interventional pain management (1,124.9 prescriptions, on average, per prescriber), pain management (921.1), anesthesiology (484.2) and physical medicine and rehabilitation (348.2). [19]

The most commonly prescribed opioid pain relievers, those classified as natural or semi-synthetic opioids such as oxycodone and hydrocodone, continue to be involved in more overdose deaths than any other opioid type. The rate of drug overdose deaths involving synthetic opioids nearly doubled between 2013 and 2014. This category includes both prescription synthetic opioids (e.g., fentanyl and tramadol) and non-pharmaceutical fentanyl manufactured in illegal laboratories.[20] 

Inexplicably, more than 90% of patients who survive a non-fatal prescription opioid overdose continue to be prescribed opioids after the event, usually by the same prescriber. This astonishing finding by the 2015 study by Larochelle and colleagues was published in the Annals of Internal Medicine.[21] Using the Optum database, the authors found that among 2848 patients who survived an overdose on opioids prescribed for chronic noncancer pain, 91% continued to receive opioid prescriptions.

This study also found 70% received prescriptions from the same clinician who prescribed the opioids prior to their initial overdose. At 2 years follow-up, the team found that patients who continued to take high-dose opioids were twice as likely to experience another overdose versus those who discontinued use after the initial overdose.

Most astonishing was the belief by the authors of the lack of nondrug alternatives for opioid painkillers:

“Finally, providers are likely aware that stopping opioid treatment can result in a patient turning to illicit opioids, including heroin, for relief. Ultimately, perceiving that it is impossible to do no harm, discouraged providers may determine that continued prescribing is their least harmful alternative.[22]

This conclusion illustrates the proverbial “elephant in the room” where medical myopia or blatant bias against chiropractors may be the real issue in this situation. Unquestionably, CAM treatments are far less harmful and far more helpful than drugs in the management of chronic pain. Perhaps medical chirophobia is one of the root causes of this opioid poisoning we now see when ill-trained MDs fail to mention nondrug solutions.

Manipulation Matters

Undoubtedly the largest illusion concerning chronic back pain specifically and musculoskeletal disorders in general is the lack of understanding that many of these chronic conditions are functional disorders due to joint dysfunction rather than anatomical issues such as arthritis or degenerative disc disease.

This point was made clear in a 2009 study, “Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain,”[23] that found opioid users mainly suffered from the following musculoskeletal disorders (MSD):

1. Back pain                                29.9%        

2. Extremity pain                         22.6%

3. Osteoarthritis                          11.1%

4. Fractures, contusions              6.4%

5. Neck pain                                 5.2%

6. Headache                                4.1%

Although it is generally understood the human musculoskeletal system consists of 640 muscles and 206 bones exist in the human body, an overlooked fact is there are over 500 total joints:

  • 361 spinal joints[24]
  • 86 skull
  • 6 pharynx & larynx  
  • 32 upper limb  
  • 31 lower limb 

Total = 516

Specifically in the spinal column itself, most people know there are 24 vertebrae connected by 23 discs, but few realize the spine has joints. Counting all the vertebral joints, sacroiliac joints, rib heads, and the pubic symphysis, new research now suggest the total is 361, a fact that is lost to physicians and patients. This total includes all synovial, symphysis, and syndesmosis joints according to Gregory D. Cramer, DC, PhD, Dean of Research at National University of Health Sciences.[25]

Considering the vast number of joints in and about the spine, it is easy to understand why manipulative therapy is a viable nondrug treatment for many of these conditions, especially the major two — back and extremity pain. Except for “fractures, contusions”, the other ailments are often amendable to manipulation and constitute 72.9% of all the opioid therapy used, which means the potential to help this quiet epidemic of chronic pain via manipulative therapy is enormous.

This is the paradigm shift the public must learn: the majority of mechanical musculoskeletal problems require manual therapies like manipulation, mobilization, self-care exercise and therapeutic massage therapy, not drugs, shots or surgery.[26]

Inept Doctors

Many doctors who are part of the problem have shown little inclination to solve it. Not only do most over-prescribe opioid painkillers, some have even balked at checking with online state registries to find out if patients are “doctor-shopping” for multiple prescriptions while others believe it is their duty to help suffering patients by prescribing pain pills despite the downside of addiction, abuse and death. [27],[28]

Another misleading fact in this epidemic of chronic pain is the mistaken belief that medical practitioners are clinically competent concerning musculoskeletal problems. In fact, researchers now agree that image of medical competency is mostly an illusion.

Pain management is rarely taught in medical schools, and surveys of physicians’ knowledge of pain management principles find significant deficits.[29],[30] Less than half of 122 U.S. medical schools require a preclinical course in musculoskeletal medicine, less than one-fourth require a clinical course, and nearly half have no required preclinical or clinical course.[31]

That may be hard for many people to accept who believe the infallibility of MDs, but most physicians have inadequate musculoskeletal education and inept in best practices treatments as many experts and studies now reveal. Numerous studies confirm most primary care physicians are inept in their training on musculoskeletal disorders,[32] more likely to ignore recent guidelines[33], and more likely to suggest spine surgery than surgeons themselves.[34]

Scott Boden, MD, MPH, currently director of the Emory Orthopaedic and Spine Center in Atlanta, admits, “Many, if not most, primary medical care providers have little training in how to manage musculoskeletal disorders.”[35]

Another study confirms that “both orthopaedic surgeons' and family physicians' knowledge of treating LBP is deficient.”[36]  In fact, orthopedic surgeons were found to be less aware of current treatment than family practitioners.

Richard Deyo, MD, MPH, author of “Watch Your Back!” also mentioned the problems with medical treatments and physician incompetence in diagnosis and treatment of low back treatments:

"Calling a [medical] physician a back-pain expert, therefore, is perhaps faint praise — medicine has at best a limited understanding of the condition. In fact, medicine's reliance on outdated ideas may have actually contributed to the problem."[37]

For an MD to pose as expert in musculoskeletal disorders, such as neck and back pain in particular, is equivalent to an MD posing as a dentist for patients with bad teeth. Instead of referring MSD patients to chiropractors, too many MDs feel competent to dole our prescription painkillers, render epidural steroid injections or refer to orthopedists for surgery rather than follow the guidelines that call for conservative care initially.

National Scandal

After decades of subjecting people to the medical treatments for chronic pain — opioid painkillers, epidural steroid injections, and disc fusion surgery — finally the research has admitted to the failure of standard medical spine treatments that have been deemed the “poster child of inefficient care” [38] by Mark Schoene, the editor of The BACKLetter, a leading international spine newsletter.

He also mentioned:

"The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate…Despite a steady stream of technological innovations over the past 15 years—from pedical screws to fusion cages to artificial discs—there is little evidence that patient outcomes have improved.”[39]

He also suggests medical spine care has become a “national scandal” and “is bringing the United States disrespect internationally.”[40] The same frustration can be heard from Dr. Richard Deyo, MD, MPH:

“People say, ‘I’m not going to put up with it,’ and we in the medical profession have turned to ever more aggressive medication, narcotic medication, and more invasive surgery.”[41]

This is quite an admission from a researcher who also found America does five times more back surgery per capita than Great Britain.[42] Among the various reasons for such a large increase, he mentioned one strong motivation included “financial incentives involving both surgeons and hospitals.”[43]

If just 50 percent of these cases could be helped via chiropractic care that would greatly reduce costs, disability, addictions and deaths. In a TIME article, “Is There a Method to Manipulation?” reporter Andrew Purvis concluded, “If spinal manipulation could ease even a fraction of that financial burden, remaining skeptics might be forced to stifle their misgivings or get cracking themselves.”[44]

 



[1] Kathleen Hennessey, “Obama says US will tackle prescription drug abuse,” Medical Press, October 21, 2015.

[2] Drug overdose deaths hit record numbers in 2014, CDC Newsroom Releases,  December 18, 2015

[4] National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, www.cdc.gov/vitalsigns/, July 2014.

[7] OxyContin: Purdue Pharma's Painful Medicine by Katherin Eban @FortuneMagazine, November 9, 2011

[8] Steven Brill, What I Learned From My $190,000 Surgery, TIME, Jan. 8, 2015

[10] Eric Palmer, The top 10 pharma companies by 2013 revenue, Fierce Pharma, March 4, 2014, http://www.fiercepharma.com/special-reports/top-10-pharma-companies-2013-revenue

[12] National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, www.cdc.gov/vitalsigns/, July 2014.

[14] Centers for Disease Control and Prevention Press Release, CDC Vital Signs: Overdose of Prescription Opioid Pain Relievers—United States, 1999-2008; 2011: www.cdc.gov/media/releases/2011/t1101_presecription_pain_relievers.html.

[15] Drug overdose deaths hit record numbers in 2014, CDC Newsroom Releases,  December 18, 2015

[16] Drug overdose deaths hit record numbers in 2014, CDC Newsroom Releases,  December 18, 2015

[17] Jonathan Chen, Overprescribing of opioids is not limited to a few bad apples, Stanford Medicine News Center, Dec 14 2015

[18] Jonathan Chen, Overprescribing of opioids is not limited to a few bad apples, Stanford Medicine News Center, Dec 14 2015

[19] Jonathan Chen, Overprescribing of opioids is not limited to a few bad apples, Stanford Medicine News Center, Dec 14 2015

[20] Rose A. Rudd, MSPH; Noah Aleshire, JD; Jon E. Zibbell, PhD; R. Matthew Gladden, PhD, Bottom of Form

Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014, Morbidity and Mortality Weekly Report (MMWR), CDC, December 18, 2015

[21] Larochelle MR, Liebschutz JM, Zhang F, Ross-Degnan D, Wharam JF. Opioid prescribing after nonfatal overdose and association with repeated overdose. A cohort study. Ann Intern Med. 2016;164:1-9. doi:10.7326/M15-0038

[22] Follow-up to Nonfatal Opioid Overdoses: More of the Same or an Opportunity for Change? EDITORIAL Annals of Internal Medicine, Editorial, December 28, 2015

[23] Denise Boudreau, PhD, Michael Von Korff, ScD, Carolyn M. Rutter, PhD, Kathleen Saunders, G. Thomas Ray, Mark D. Sullivan, MD, PhD, Cynthia Campbell, PhD, Joseph O. Merrill, MD, MPH, Michael J. Silverberg, PhD, MPH, Caleb Banta-Green, and Constance Weisner, DrPH, MSW. “Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain,” Pharmacoepidemiol Drug Saf. 2009 December ; 18(12): 1166–1175. doi:10.1002/pds.1833.

[24] Cramer, G.; Darby, S. 2014 Clinical anatomy of the spine, spinal cord, and ANS. 3rd Edition, Elsevier/Mosby, St. Louis, 559 illustrations, 672pp. Appendix I, pp. 638-642.

[25] Cramer, G.; Darby, S. 2014 Clinical anatomy of the spine, spinal cord, and ANS. 3rd Edition, Elsevier/Mosby, St. Louis, 559 illustrations, 672pp. Appendix I, pp. 638-642.

[26] De Leon Casada. Opioids for Chronic Pain: New Evidence, New Strategies, Safe Prescribing The American Journal of Medicine, 126(3s1):S3–S11. (2013).

[27] America's deadliest drug problem: Our view, The Editorial Board, USA Today, December 22, 2015

http://www.usatoday.com/story/opinion/2015/12/21/cdc-opioids-heroin-overdoses-doctors-editorials-debates/77708774/

[28] Jonathan Chen, Overprescribing of opioids is not limited to a few bad apples, Stanford Medicine News Center, Dec 14 2015

[29] Lebovits AH, Florence I, Bathina R, Hunko V, Fox MT, Bramble CY. Pain knowledge and attitudes of healthcare providers: practice characteristic differences. Clin J Pain. 1997;13:237–243. [PubMed]

[30] Wolfert MZ, Gilson AM, Dahl JL, Cleary JF. Opioid analgesics for pain control: Wisconsin physicians' knowledge, beliefs, attitudes, and prescribing practices. Pain Med. 2010;11:425–434. [PubMed]

[31] Day C., Yeh A., Franko O., Ramirez M., Krupat E. (2007) Musculoskeletal Medicine: An Assessment of the Attitudes of Medical Students at Harvard Medical School, Academic Medicine 82: 452-457

[32] EA Joy, S Van Hala, “Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/11 (November 2004).


[33]
PB Bishop et al., “The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A Randomized Controlled Trial On The Effectiveness Of Clinical Practice Guidelines In The Medical And Chiropractic Management Of Patients With Acute Mechanical Low Back Pain,” presented at the annual meeting of the International Society for the Study of the Lumbar Spine Hong Kong, 2007; presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; Spine, in press.


[34]
SS Bederman, NN Mahomed, HJ Kreder, et al. In the Eye of the Beholder: Preferences Of Patients, Family Physicians, And Surgeons For Lumbar Spinal Surgery,” Spine 135/1 (2010):108-115.

[35] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28(2003):524-525.

[36] Finestone AS1, Raveh A, Mirovsky Y, Lahad A, Milgrom C., “Orthopaedists' and family practitioners' knowledge of simple low back pain management,” Spine (Phila Pa 1976) 2009 Jul 1;34(15):1600-3.

[37] Deyo, RA. Low -back pain., Scientific American, pp. 49-53, August 1998.

[38] The BACKPage editorial vol. 27, No. 11, November 2012.

[39] The BackLetter, vol.12, no. 7, pp.79 July, 2004. The BackPage editorial, The BackLetter, pp. 84, vol. 20, No. 7, 2005

[40] U.S. Spine Care System in a State of Continuing Decline?, The BACKLetter, vol. 28, No. 10, 2012, pp.1

[41] G Kolata, “With Costs Rising, Treating Back Pain Often Seems Futile,” NY Times (February 9, 2004)

[42] DC Cherkin, RA Deyo, et al. An International Comparison Of Back Surgery Rates,” Spine, 19/11 (June 2004):1201-1206.

[43] “New Study Demonstrates A Three-Fold Increase N Life-Threatening Complications With Complex Surgery,” The BACKLETTER, 25/6 (June 2010):66

[44] Andrew Purvis, “Is There a Method to Manipulation?” TIME magazine, Sept. 23, 1991.  


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