Research: opioid crisis interventions, chiropractic and learnings from Germany

With only one chiropractic school in the entire country, can Germany institute opioid crisis interventions to tame opioid overuse?

Germany had the second-highest opioid prescribing rate in 2018, according to defined daily doses per million inhabitants per day. It is estimated that 70% of prescriptions for opioids in Germany are for chronic pain other than cancer pain. Non-cancer chronic pain syndromes like chronic low back pain and osteoarthritis cause the greatest amount of disability worldwide.¹ This commentary will evaluate if chiropractic treatment and opioid crisis interventions can be an effective non-pharmacological therapy in order to reduce opioid intake in Germany.

According to the 2010 prescribing data for mild opioids, the majority of prescriptions were issued for back pain (23.4%) and spondylosis (9.3%). In 2010, back pain was the most common diagnosis for strong opioids (18.0%).² Drug-based opioid analgesics are used to treat chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia, and low back pain over short, intermediate or long-term periods of time. When nonpharmacological therapies and/or other drugs fail to relieve chronic noncancer pain or are ineffective, intolerant or contraindicated, opioids remain an option.³

Opioid efficacy for low back pain

An analysis of 10 randomized controlled trials involving more than 3,000 participants was conducted by Welsch, et al., in 2015. Short term (4-12 weeks) treatment of low back and osteoarthritis pain with nonopioid analgesics improved physical function and tolerability more than opioids.⁴

STUDY	Welsch, et al.
YEAR	2015
CONDITION	Chronic non-cancer pain
STUDY	Systematic review and meta-analysis
INCLUSION	Randomized controlled trials
NUMBER OF STUDIES	10
NUMBER OF PATIENTS	3,046
MEASURE	Physical function and tolerability
RESULTS	For pain caused by low back or osteoarthritis in the short term (4-12 weeks), nonopioid analgesics are superior to opioids.

 

Sixteen randomized controlled trials were reviewed and meta-analyzed in 2022 by Nury, et al. Researchers found that opioid therapy for chronic low back pain for 4-15 weeks (short or intermediate term) may reduce pain clinically relevant but may also result in more adverse gastrointestinal and nervous system events than placebo. Disability appears to be unaffected.⁵

STUDY	Nury, et al.
YEAR	2022
CONDITION	Chronic low back pain
STUDY	Systematic review and meta-analysis
INCLUSION	Placebo-controlled randomized controlled trials
NUMBER OF STUDIES	16
MEASURE	Pain and disability
RESULTS	Compared with placebo, opioid therapy for 4-15 weeks was effective in reducing pain clinically relevantly (compared with 4-15 weeks of no opioid treatment) but caused more adverse effects on gastrointestinal and nervous systems, while little effect on disability was seen with these opioid crisis interventions.

 

Opioid crisis interventions: chiropractic treatment/spinal manipulation

It is estimated that 1 in every 50,000 to 1 in every 3.7 million manipulations and mobilizations for low back pain will cause adverse effects.

If performed in accordance with the rules of the European Training Requirements of the UEMS, manipulation and mobilization for low back pain are practically risk-free and safe.⁶ During the second half of the 20th century, manual treatment was introduced to Germany primarily through manual medicine.⁷ Based on a retrospective study by Rhee, et al., conducted on 13,760 patients who had back surgery, narcotic drugs were significantly more likely to be used after one week than those who did not.

A chiropractic treatment for low back pain, on the other hand, was less likely to lead to patients taking narcotic drugs within a week following the treatment.⁸

Chiropractic efficacy on physical function

According to Rubinstein, et al., over 800 people participated in seven randomized controlled trials. A standardized measured difference between spinal manipulative therapy and standard therapy after one month was -0.41.⁹

STUDY	Rubinstein, et al.
YEAR	2019
CONDITION	Low back pain
STUDY	Systematic review and meta-analysis
INCLUSION	Randomized controlled trials
NUMBER OF STUDIES	7
NUMBER OF PATIENTS	835
MEASURES	Physical function for chronic low back pain
RESULTS	One month after the start of the spinal manipulative therapy, the standardized difference (SMD) after the first month of treatment was -0.41.

Opioid effect on physical function

According to Petzke, et al., four randomized controlled studies involving over 1,800 patients were reviewed and meta-analyzed in 2015. A standardized measure of difference in physical functioning between opioids and placebo was found to be – 0.22.¹⁰

STUDY	Petzke, et al.
YEAR	2015
CONDITION	Chronic low back pain
STUDY	Systematic review and meta-analysis
INCLUSION	Randomized, placebo-controlled studies
NUMBER OF STUDIES	4
NUMBER OF PATIENTS	1895
MEASURES	Physical function
RESULTS	Standardized measured difference of -0.22 showed opioids improved physical function better than placebo

Low back pain, economic burden and absenteeism

A topic not mentioned in this commentary is the economic burden of low back pain. Germans pay over 7,000 euros per year in direct back pain costs. Germany’s low back pain costs were largely due to work absenteeism.¹¹

Osteoarthritis was mentioned in the introduction as a major cause of opioid intake in Germany. Over 8,000 people participated in 20 randomized controlled trials conducted by Schaefert and colleagues in 2015. Researchers found that, compared to baseline, there was a small effect size of pain intensity reduction and physical disability reduction on average. The study concluded that pain associated with chronic osteoarthritis cannot be treated first-line with opioids according to current evidence-based guidelines.¹²

More than 3,000 patients were included in the systematic review and meta-analysis conducted by Bialas, et al. Within the context of open-label extension studies of randomized controlled trials, low-quality evidence on opioid efficacy, tolerability and safety for chronic low back pain, osteoarthritis and diabetic polyneuropathic pain is lacking. Adverse events and deaths contribute to higher dropout rates with longer study durations.¹³

Increasing non-pharmacological therapies

Germany is the second country in the world with the most prescriptions for opioids. At least 33% of the prescriptions for opioids in Germany are due to low back pain or spondylosis.

The current protocol for the management of low back pain in Germany stipulates that non-pharmacological therapies must be tried before prescribing opioid medications. Given the safety and efficacy in improving physical function for low back pain, chiropractic spinal manipulation should be considered as a non-pharmacological therapy in Germany for opioid crisis interventions to reduce opioid intake and the economic burden associated with low back pain.

Currently, there is only one chiropractic school in Germany and hopefully the number increases in the coming years.

ADRIAN ISAZA, PHD, DC, MD, is both a physician and an academic. As an academic he co-authored the book “Functional Foods and Nutraceuticals in Metabolic and Non-Communicable Diseases.” He also teaches for the University of Integrated Health in the Doctor of Integrative Medicine program. He holds a diplomate in diagnosis awarded by the American Board of Chiropractic Internists and a diplomate in nutrition awarded by the American Clinical Board of Nutrition. Moreover, he is a certified Chiropractic Acupuncture Practitioner and has a PhD in medical sciences. He practices medicine full-time in Tampa, Fla., and has published more than 60 papers advocating the use of alternative medicine.

CITATIONS 

1. Petzke F, Bock F, Hüppe M, et al. Long-term opioid therapy for chronic noncancer pain: second update of the German guidelines. PR9. 2020;5(5):e840
2. Rosner B, Neicun J, Yang JC, Roman-Urrestarazu A. Opioid prescription patterns in Germany and the global opioid epidemic: Systematic review of available evidence. Cheungpasitporn W, ed. PLoS ONE. 2019;14(8):e0221153
3. Koautoren für die Konsensusgruppe der 2. Aktualisierung der S3-Leitlinie LONTS, Häuser W, Bock F, et al. Empfehlungen der zweiten Aktualisierung der Leitlinie LONTS: Langzeitanwendung von Opioiden bei chronischen nicht-tumorbedingten Schmerzen. Schmerz. 2020;34(3):204-244
4. Welsch P, Sommer C, Schiltenwolf M, Häuser W. [Opioids in chronic noncancer pain-are opioids superior to nonopioid analgesics? A systematic review and meta-analysis of efficacy, tolerability and safety in randomized head-to-head comparisons of opioids versus nonopioid analgesics of at least four week’s duration]. Schmerz. 2015;29(1):85-95
5. Nury E, Schmucker C, Nagavci B, et al. Efficacy and safety of strong opioids for chronic noncancer pain and chronic low back pain: a systematic review and meta-analyses. Pain. 2022;163(4):610-636.
6. Locher H. [Spinal manipulation therapy in low back pain : Why? When? Where? How?]. Orthopade. 2022;51(4):283-293.
7. Kladny B. [History of conservative spinal therapy]. Unfallchirurg. 2015;118 Suppl 1:12-18.
8. Rhee Y, Taitel MS, Walker DR, Lau DT. Narcotic drug use among patients with lower back pain in employer health plans: a retrospective analysis of risk factors and health care services. Clinical Therapeutics. 2007;29(11):2603-2612
9. Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019;364:l689
10. Petzke F, Welsch P, Klose P, Schaefert R, Sommer C, Häuser W. [Opioids in chronic low back pain. A systematic review and meta-analysis of efficacy, tolerability and safety in randomized placebo-controlled studies of at least 4 weeks duration]. Schmerz. 2015;29(1):60-72.
11. Juniper M, Le TK, Mladsi D. The epidemiology, economic burden, and pharmacological treatment of chronic low back pain in France, Germany, Italy, Spain and the UK: a literature-based review. Expert Opinion on Pharmacotherapy. 2009;10(16):2581-2592
12. Schaefert R, Welsch P, Klose P, Sommer C, Petzke F, Häuser W. Opioide bei chronischem Arthroseschmerz: Systematische Übersicht und Metaanalyse der Wirksamkeit, Verträglichkeit und Sicherheit in randomisierten, placebokontrollierten Studien über mindestens 4 Wochen. Schmerz. 2015;29(1):47-59.
13. Bialas P, Maier C, Klose P, Häuser W. Efficacy and harms of long‐term opioid therapy in chronic non‐cancer pain: Systematic review and meta‐analysis of open‐label extension trials with a study duration ≥26 weeks. Eur J Pain. 2020;24(2):265-278.