Reducing opioid use for back, neck and shoulder pain starts with interprofessional collaboration

The COVID-19 pandemic has become an unplanned experiment in what it means to have reduced access to care. This fallout, combined with makeshift home offices and other factors, has created a perfect storm for those suffering from spine, muscle and joint – or musculoskeletal (MSK) – conditions. Unfortunately, it also added fuel to the opioid crisis, particularly in treating chronic back pain.

According to the Ontario Medical Association (OMA), the pandemic created an astonishing backlog of nearly 22 million health-care services from March 2020 to May 2022. This significantly diminished access to care has affected not only primary care and emergency departments but also regulated health-care professionals, such as chiropractors, registered massage therapists and physiotherapists, who could have provided relief.

In turn, for people in labour-intensive roles or working from do-it-yourself home offices, the reduced access to health-care professionals combined with increased stress has taken a significant toll on their MSK system. These consequences are no small issues. MSK conditions and related pain account for the largest share of the global disability burden.

Fortunately, there are several ways to address back, neck and shoulder pain that doesn’t require medication.

More than 50 per cent of opioid users have reported back pain

It may come as a surprise that back pain has been reported in more than half of regular opioid users. In fact, it’s one of the most common diagnoses emergency and family physicians cite for prescribing opioids.

Although many patients are prescribed opioids for pain, a 2016 systematic review and meta-analysis found that although opioid medications provide modest, short-term relief for people with chronic back pain, evidence of long-term efficacy is lacking.

To make matters worse, opioid-related deaths in Ontario have increased since 2019, or prior to the pandemic, according to Public Health Ontario (PHO). Some of these fatalities are pandemic-related, while others are indicative of the ongoing opioid crisis. However, there are ways to help address the crisis and reduce opioid-related deaths related to low back pain.

Manual therapy: A medication-free alternative for low back pain

Over the past 10 years, research has demonstrated that treatments chiropractors provide, such as spinal manipulation and therapeutic exercise programs, can relieve low back, neck, shoulder or other MSK pain. For example, a 2020 Pain Medicine journal study reported patients with spinal pain who saw a chiropractor were half as likely to fill an opioid prescription compared to those who did not. And the type of care chiropractors provide is now globally recognized as an evidence-based first- and second-line approach for low back pain.

In addition, a 2017 Canadian guideline for opioid therapy and chronic noncancer pain recommends co-ordinated multidisciplinary collaborations between physicians and other health-care professionals, such as chiropractors. Similarly, Health Quality Ontario (HQO) suggests that making better use of non-medical treatments to manage acute and chronic pain will reduce the number of people who use opioids in the long-term. As well, in its Opioid Prescribing for Chronic Pain standard, HQO recommends spinal manipulation in conjunction with an active physical therapy or exercise program.

This means that Ontario’s health-care system has a recognized and recommended option for treating low back and other spine, muscle and joint pain aside from opioids. Chiropractors are eager to build on their collaborations with health-care professionals to further leverage this option for patients.

Patients with spinal pain who saw a chiropractor were half as likely to fill an opioid prescription compared to those who did not.

Interprofessional collaboration is imperative

To best support patients in reducing their pain and risk of opioid dependency, interprofessional collaboration is imperative. This is because these issues affect all aspects of a patient’s life, including their work, social interactions, family life, finances and mental health. For example, a recent study in the International Journal of Environmental Research and Public Health found a mutual link between major depression and back pain.

Working together, each professional plays a distinct and important role. Spine, muscle and joint experts, such as chiropractors, can target the cause of the MSK pain and connect to affected areas of the patient’s life. In turn, primary-care providers, as well as social workers and other health-care professionals, are essential for the depth of expertise they bring to the complexity of a patient’s situation.

To achieve the best outcomes, all care team members connected to the care plan should be aware of what’s happening at each stage. As a patient’s mobility improves, for example, it’s important that the care team understands the chiropractor’s next steps in the treatment. For example, if the patient is taking on more exercise, the physician or nurse practitioner (NP) can closely monitor the medication dosage and adjust as required.

This ongoing communication, coupled with a care plan that clearly defines key stages and touchpoints between providers, will ensure the patient’s overall goals are met. It also enhances patient care, empowering the care team to achieve better outcomes for many Ontarians.

OCA’s Opioid and Pain Reduction Collaborative

Not surprisingly, there’s a desire at all levels of health care and governments to address the opioid crisis and research its root cause. Interestingly, some of this research reveals significant links to MSK pain, including scenarios in which patients presenting in emergency departments are introduced to opioids to relieve the pain.

At the Ontario Chiropractic Association (OCA), we’re helping address the opioid crisis head-on. We’ve partnered with other medical professionals to develop the Opioid and Pain Reduction Collaborative. It is designed to help manual therapists like chiropractors and registered massage therapists co-ordinate care plans with patients and their physicians or NPs. In this scenario, manual therapists work within their professional scope of practice to treat patients’ back, shoulder or neck conditions. At the same time, patients’ prescribing health professionals taper their opioid dosage at a pace that works with their manual therapy.

As part of this strategy, we worked with the Centre for Effective Practice (CEP) to develop an evidence-based clinical tool on manual therapy for MSK pain to inform physicians and NPs with the best available evidence. Since its June 2020 launch, it has been accessed more than 7,500 times. Our collaborative also provides a concise treatment-plan toolkit for chiropractors to support collaborations between manual therapists, patients and their prescribing health-care professionals.

We also have partnered with the Canadian Memorial Chiropractic College (CMCC) to develop a continuing education course on the role of chiropractic in opioid use reduction. Cuong Ngo-Minh, course co-author and physician at Ottawa’s Somerset West Community Health Centre, says “this course provides the most current information about opioids and tools to recognize and address suspected opioid intoxication and misuse.”

Overall, if we can provide the best MSK care at the right place, which is often outside hospitals, as well as at the right time, we can help our health-care system efficiently address the pandemic’s backlog of patient needs, as well as address the opioid crisis. Then, our publicly funded system can devote its resources to priorities such as cardiac and cancer care that can’t be delivered elsewhere.

This is a watershed moment for all of us to work together to change the outcomes for Ontarians who depend on opioids to relieve their MSK pain.