Chiropractic care and technologies such as sEMG open new pain relief avenues for an opioid treatment program
MODERN MEDICINE HAS MADE GREAT STRIDES in the treatment of trauma, heart disease and cancer. In the modern battlefield, the soldier who lives one minute after an IED explosion will today most likely survive. Between 1984-2014, there was a 50% decline in heart disease mortality. New medications have reduced many forms of cancer to a chronic disease.
On the other hand, the treatment of chronic pain using opioids has been nothing less than a disaster. From experience, converting patients from opiates to chiropractic care is a very effective, safe approach to resolving chronic pain and, in turn, the opioid epidemic.
Big pharma and the rise of opioids
A 1947 editorial in the Journal of the American Medical Association advised against giving opioids to cancer patients. In 1988, conversely, a letter to the editor in the prestigious New England Journal of Medicine suggested that only 1% of pain patients become addicted to prescribed opioids — a claim which has since been proven false.
By 1987, many medical doctors believed opioids were optimal for patients with chronic nonmalignant pain. By 1999, the Joint Commission for the Accreditation of Hospitals was mandating the use of the so-called “fifth vital sign.” This is a misnomer. In medicine, a “sign” is something that can be measured objectively. The fifth vital sign was measuring a symptom. Often addicts would tell the doctor what they thought he or she wanted to hear. Unfortunately, pain assessment was qualitative, lacking the objectivity of measures such as blood pressure or pulse, etc.
The use of hydrocodone tripled in the 2000s. “Big Pharma” persuaded medical doctors that opioids were safe and nonaddictive when used for the treatment of pain. At the present time, up to 130 people die daily of an opioid overdose, with more than 70% receiving their first narcotic pills from their doctor’s office. This was not the case with heroin addicts in previous years. One unfortunate by-product of opioid use is a paradoxical increase in pain and anxiety above a threshold dose.
Opioids in the body
The body has a natural opioid system. Several different opioids, including endorphins, are released as a result of exercise, eating and socializing.
Opium and the synthetic form, morphine, act on these same opioid receptors in the brain. Opioids are valuable when treating acute trauma, post-surgery, and with heart attacks. Common Schedule II (per DEA regulations) opioids are hydrocodone, oxycodone, Percocet, Vicodin, codeine and fentanyl. Tramadol is a commonly-used medication which has similar pain-relieving qualities but is considered to have a lower risk of addiction. It is a Schedule IV drug in the same class as benzodiazepines. Heroin is an illegal opioid (Schedule I) which was developed in the late 19th century as a cure for morphine addiction.
The pain pathways and opioids
Why do pain patients become addicted to opioids? The answer lies in the pain pathway. When the impulses reach the central nervous system there is a bifurcation into the somatosensory cortex and the amygdala. Part of the amygdala is the medial forebrain bundle (MFB, which passes through the lateral hypothalamus and basal forebrain). A component pathway of this MFB is the mesolimbic pathway, which is a collection of dopaminergic neurons that project from the ventral tegmental area to the nucleus accumbens. This nucleus is the final common pathway for all addictions including opioids, gambling, processed sugar, etc.
Opioids disrupt the natural reward system by flooding the brain with large amounts of dopamine. They “hijack” the mesolimbic pathway. After a period of use, opioid receptors become less sensitive to opioids. As the body gets used to a regular dose of opioids it slows the production of natural opioids. This results in an individual requiring a larger dose to achieve the same effect. Patients addicted to opioids experience uncontrollable cravings for opioids that persist after they stop taking the drug.
A prescription for disaster
It is relatively easy for a patient to get a prescription for opioids. They simply go to their PCP and complain about low-back pain. An X-ray will most likely show some degenerative changes, and an MRI of the lumbar spine will most likely be abnormal. It has been found in repeated studies that lumbar disc disorders, including herniation, can be seen in up to 65% of individuals who are completely asymptomatic. However, a drug seeker (or a doctor who is making a lot of money prescribing high doses of opioids) can use an abnormal test to “justify” the need for opioids.
Some unscrupulous doctors have even used MRIs from other patients to “document” the need for high doses of opioids in their “patients.” Diversion of these opioids has become a big problem. Many medical doctors have lost their licenses and gone to prison because of this abuse. Often, they have started using these opioids themselves and have developed severe impairments in judgment.
sEMG + chiropractic
Using technologies such as static and dynamic surface electromyography (sEMG), the DC can objectively discriminate between patients with mechanical sources of low-back pain and those who are actually experiencing pain due to opioid addiction.
DCs can provide this easy-to-comprehend data to both the PCP and patient, so all are focused on the same solution. Simply stated, if the patient claims to be in pain, but the sEMG data is normal, they are most likely experiencing the pain associated with opioid addiction. If the sEMG test data is abnormal, this would lead to the conclusion that the patient may be experiencing a mechanical source of low-back pain; something the chiropractor is well-trained to treat without the use of drugs. By sharing patient progress with an objective marker such as the sEMG, there is a greater likelihood the patient will be compliant and maintain interest in resolving the pain without the need for opioids.
Data can lead the way
Numerous research studies have demonstrated that sEMG can document the presence and severity of spine disorders. In a meta-analysis performed by University of Michigan researchers, sEMG when combined with range of motion was better at determining presence or absence of low-back pain than range of motion or dynamic sEMG alone. The researchers reported that when range of motion was simultaneously measured with dynamic sEMG, there was excellent sensitivity and specificity (88.8% and 83.1%, respectively).
We live in a data-driven world, and objective data can provide a compelling argument for convincing a patient to choose chiropractic care over opioid use. The long-term benefit of transitioning patients from opioids to chiropractic care includes not only cost savings, but improved quality of life for the patient.
ALEX AMBROZ, MD, MPH, CIME, is in private practice in West Virginia. He has used surface EMG since 1994 and has published research on this subject in peer-reviewed journals. He has lectured on the topic at numerous scientific symposiums.
VERN SABOE, JR., DC, DACAN, DABFP, FACO, is board certified in chiropractic neurology, forensic science and orthopedics. Now in his 38th year of private practice, he has served on many state of Oregon policy-making groups helping to improve access to chiropractic services in Oregon.
