Looking Beyond the Opioid Misuse Epidemic: The Role for Non-Pharmacologic Treatment of Musculoskeletal Pain

1. First-line Treatment as Primary Prevention of Opioid Misuse

Non-pharmacological treatments, including reassurance, exercise, chiropractic spinal manipulation, acupuncture and massage are recommended as first-line treatments for pain in numerous best practice guidelines including, among others, the American College of Physicians, (6) The Joint Commission and CDC. (7) Non-pharmacologic treatment measures such as exercise therapy, spinal manipulation, acupuncture and yoga are also recommended as alternatives to opioid prescribing in a 2018 report published by the Minnesota Department of Human Services.

Best practice guidelines recommend prioritizing conservative courses of chiropractic care, acupuncture, and massage before more invasive treatments. This
approach is more likely to result in better patient outcomes, with fewer side-effects. Care pathways and health system designs that steer pain patients toward non-drug options first would prevent exposure to high-risk therapies like opioids and other narcotics, injections, and surgery. Compelling new research shows that when patients with musculoskeletal problems seek the care of CIH providers, the likelihood of a prescription for pain medication of any kind is greatly reduced. (8)

2. Secondary Prevention of Opioid Misuse for at-risk Populations

A growing segment of the US population has faced addiction in the past. Many more are at risk for addiction, or are otherwise considered to be vulnerable populations at higher than average risk for poor outcomes with medication use (e.g. the elderly, pregnant women, children and adolescents). This creates additional need to ease patient access to non-pharmacological therapies, and provide safer pain management options for at risk populations. Integrative pain management can be critical to preventing relapse in addicts who face surgery, suffer from acute injuries, or are in need of chronic pain management. Integrative care wraps a team of healthcare providers and support services around pain patients, coordinating individualized pain management across providers and addiction specialists, preventing relapse or increased risk exposure with opioids.

3. Tertiary Prevention through Pain Management of Addicted Individuals Substance abuse problems are often an unintended consequence of inadequate pain relief

This can occur through the abuse of prescription pain relievers, as well as the use of illicit drugs to self-medicate. Back pain sufferers report higher rates of marijuana, cocaine, methamphetamine and heroin use than adults without back pain. (9) For those who are substance addicted, many continue to experience pain. Inadequate relief prevents some from pursuing substance abuse rehabilitation, makes recovery more difficult, and presents a persistent risk for relapse. Increasing awareness and access to non-drug pain treatment options may help some initiate rehabilitation, support those in rehabilitation, and provide an additional measure of prevention for relapse. CIH providers should be considered an important part of addiction teams, taking a multi-modal approach to both addiction recovery and pain management.

• The Penny George Institute for Health and Healing, within the Allina Health system, offers the most comprehensive array of integrative medicine services. This includes integrating acupuncture into emergency departments of affiliated hospitals, including Abbott Northwestern Hospital, St. Francis Regional Medical Center, New Ulm Medical Center, Owatonna Hospital, The Mother Baby Centers, and the Virginia Piper Cancer Institute.
• HealthPartners has chiropractic doctors on staff at a quarter of locations throughout the Twin Cities.
• Integrative health is a featured component of the Hennepin HealthCare system, where acupuncturists and chiropractic doctors work collaboratively with board certified family medicine physicians and others. Most of the CIH providers there are graduates of Northwestern Health Sciences University.
• In St. Paul, medically underserved patients gain access to chiropractic care in two Federally Qualified Health Centers – Minnesota Community Care and Open Cities Health Center. Northwestern Health Sciences University supplies student-interns to assist chiropractic faculty providers, increasing capacity to care for special populations.
• In rural northern Minnesota communities, chiropractors are relieving the burden of back pain cases from primary care physicians in clinics operated by Sanford Health.
• In 2017, the Minneapolis VA Health Care System was designated a Whole Health Design Site. There, chiropractors and acupuncturists are part of a healthcare team “… focused on empowering and equipping Veterans to take charge of their health and well-being.”
• Pediatrician Lynn Gershan, MD, at the University of Minnesota Masonic Children’s Hospital in Minneapolis is a strong advocate for the acupuncturists who are part of her integrative healthcare team.
• Low-income patients of the Phillips neighborhood in Minneapolis have access to chiropractic, acupuncture and massage therapy services in the Integrative Clinic of Minnesota, in addition to services provided by the University of Minnesota Medical School and the Alder Graduate School.

In addition to health systems and hospitals, an increasing number of chiropractic doctors, licensed acupuncturists and massage therapists are joining each other in private practice clinics throughout Minnesota where patients can receive non-pharmacological care for back pain and other musculoskeletal programs.