Addictionology, Back pain, and chiropractic
Mark Studin DC, FASBE(c), DAAPM
Paolo Coppola MD, FACEP
Reference: Studin M., Coppola P., (2023) Addictionology, Back Pain and Chiropractic, Dynamic Chiropractor (41) 2, 53-55
According to the National Institutes of Health, “Unhealthy substance use, and addiction is the nation’s largest preventable health problem, yet only about 10% of patients receive treatment for it. This new subspecialty is important in helping eliminate the personal and public health consequences and the stigma associated with addiction by reinforcing that it is a preventable, treatable disease and by providing patients with access to credentialed physicians. Addiction Medicine (ADM) is now a recognized physician subspecialty of the American Board of Medical Specialties.”1
Back pain is the leading cause of disability worldwide, where ~37% of the population is affected by low back pain.2 Acute low back pain (LBP), if unresolved, is considered chronic if it persists for more than 3 months and is experienced by 70-80% of adults in their lifetime.3 85% -90% of patients with chronic low back pain (CLBP) have pain that cannot be determined from a definitive pathoanatomic structure and therefore termed “non-specific.”4 Non-specific LBP in an overall setting (acute and chronic) is defined as LBP with no attributable known cause and represents 90% - 95% of cases.5
Of those 85% - 90% of CLBP patients and upwards of 95% for all cases, they arise from acute low back pain with no definitive pathoanatomic cause (mechanical spine pain with no fracture, tumor, infection, or herniation). Of these acute patients, medical primary care providers prescribe LBP patients opiates in 24.4%, urgent care facilities in 40.8%, and emergency room physicians in 43.1% of cases.6
Of the 95% non-specific back pain, the literature has provided extensive evidence of the etiology when describing the genesis of spinal pain. Spinal meniscoids impingements, which are intra-articular folds of the synovial membrane, provide evidence of a pathoanatomical source of pain.7 In acute and chronic settings, there is a direct activation of nociceptor afferents where the sensitization and de-sensitization of pro- and anti-inflammatory mediators may modulate spinal pain. There is also central sensitization with widespread issues of mechanical pain sensitivity originating in the disc, facet, joint capsules, and ligaments.8
A chiropractic spinal adjustment (manipulation) inhibits neck and back pain through segmental and peripheral mechanisms regulating the inflammatory response.9 The meniscoid entrapment, which created pain, also creates a “tractioning” effect on the zygapophyseal joint capsule (mechanoreceptors), further leading to central sensitization. A chiropractic high velocity, low amplitude thrust/adjustment (HVLAT) stretches the joint, providing “joint gapping” and the “treatment of choice” for meniscoid entrapment, and reduces the pain created by the biomechanical pathology.10
In 2018 it was reported that average annual charges per person for filling opioid prescriptions were 74% lower among chiropractic patients compared with other forms of treatment. For clinical services provided at office visits for low back pain, average annual charges per person were 78% lower among chiropractic patients compared with other forms of treatment. The likelihood of a prescription for an opiate analgesic was 55% lower among chiropractic patients compared with other forms of treatment.11 In 2020, the prevalence of chiropractic care among patients with spinal pain varied between 11.3% and 51.3%. The proportion of patients receiving an opioid prescription was lower for chiropractic users compared with other forms of treatment. Chiropractic patients had 64% lower odds of receiving an opioid prescription compared with other forms of treatment.
In 2016, it was reported that medical care ended spinal-related compensation 12% longer than chiropractic, and physical therapy care required 239% more time to end full compensation than chiropractic. Medical care also required 20% more time, and physical therapy 313% more time versus chiropractic care regarding partial compensation.12
Despite the evidence in the literature, prominent medical establishments such as the Mayo Clinic still list chiropractic as an alternative footnote after listing physical therapy, drugs (including antidepressants and narcotics), surgery, implanted nerve stimulators, a radiofrequency neurotomy (surgery), steroid injections, all of which did nothing as primary treatment modalities. Herein lies part of the societal problem of dependence and the necessity for creating an addiction specialist.13
However, with the advent of an addiction specialist, they have understood and searched for a solution to the underlying cause of the fifth most prevalent reason for visiting a US doctor, low back pain.14 Addiction specialists are searching for the eradication of the cause of the pain that has led to opiate use initially, and chiropractic outcomes have warranted inclusion into their treatment plans for the management of substance addiction. The challenge that addiction specialists must overcome with using chiropractic is coverage issues where Medicaid and Workers’ Compensation systems place unrealistic roadblocks. These systems, in every state, offer full coverage for services that realize 64% higher opiate use and a 313% increase in disability yet still prevent patients from receiving “evidence-based care” that prevents opiate addiction.
Despite these outcomes, money is being drained from our healthcare system, lives are being severely disrupted, and people are dying unnecessarily.
1. About the Addiction Medicine Specialties (2018), Retrieved from: https://nida.nih.gov/nidamed-medical-health-professionals/health-professions-education/adm-fellow-toolkit/about-addiction-medicine-subspecialty
2. Gevers-Montoro, Carlos, et al. "Chiropractic spinal manipulation prevents secondary hyperalgesia induced by topical capsaicin in healthy individuals." Frontiers in Pain Research (2021): 33.
3. Paolucci, Teresa, et al. "Chronic low back pain and postural rehabilitation exercise: a literature review." Journal of pain research 12 (2019): 95.
4. Tagliaferri, Scott D., et al. "Domains of chronic low back pain and assessing treatment effectiveness: a clinical perspective." Pain Practice 20.2 (2020): 211-225.
5. Oliveira, Crystian B., et al. "Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview." European Spine Journal 27.11 (2018): 2791-2803.
6. Azad, Tej D., et al. "Initial provider specialty is associated with long-term opiate use in patients with newly diagnosed low back and lower extremity pain." Spine 44.3 (2019): 211-218.
7. Farrell, S.F., et al. “Cervical spine meniscoids: an update on their morphological characteristics and potential clinical significance.” European Spine Journal (2017) 26:939–947
8. Gevers‐Montoro, Carlos, et al. "Neurophysiological mechanisms of chiropractic spinal manipulation for spine pain." European Journal of Pain 25.7 (2021): 1429-1448.
10. Evans, David W. "Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories." Journal of manipulative and physiological therapeutics 25.4 (2002): 251-262.
11. Whedon, James M., et al. "Association between utilization of chiropractic services for treatment of low-back pain and use of prescription opioids." The Journal of Alternative and Complementary Medicine 24.6 (2018): 552-556.
12. Corcoran, Kelsey L., et al. "Association between chiropractic use and opioid receipt among patients with spinal pain: a systematic review and meta-analysis." Pain Medicine 21.2 (2020): e139-e145.
13. Back Pain (2021) Mayo Clinic, retrieved from https://www.mayoclinic.org/diseases-conditions/back-pain/diagnosis-treatment/drc-20369911
14. Urits, Ivan, et al. "Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment." Current pain and headache reports 23.3 (2019): 1-10.
Dr. Mark Studin is a chiropractor who graduated from New York Chiropractic College in 1981. He is currently an Adjunct Associate Professor of Chiropractor at the University of Bridgeport, College of Chiropractic, and an Adjunct Professor at Cleveland University Kansas City, College of Chiropractic.
Dr. Studin is also a clinical instructor for The State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education, where he teaches numerous courses related to trauma and patient management.
Dr. Coppola simultaneously earned a Bachelor of Science in mathematics at New York University and a Bachelor of Engineering at The Cooper Union in New York in 1990. He completed his medical degree at The Mount Sinai School of Medicine in New York.
He completed his residency in emergency medicine at the Johns Hopkins Hospital in Baltimore, Maryland. To better serve the diverse communities in New York City, Dr. Coppola is multilingual and speaks English and Italian fluently. He is board-certified in addiction medicine by the