OPINION -- Oregon Health Plan patients with acute, subacute, or chronic low back pain conditions currently have a very difficult if not impossible ability to see a chiropractic physician for spinal manipulation, but have much less or no difficulty receiving prescriptions for harmful pain medications including opioid narcotics from their medical doctor and a change must occur. Chiropractic physicians are the first contact portal of entry primary care providers who have focused on health promotion and overall wellness for decades, well before the term “wellness” was fashionable within the medical profession. There are many evidence-based natural drug-free remedies that work and many drugs that don’t. It’s time for a change in Oregon and that change must include how we treat low back pain in the Medicaid population.
Low back pain is one of the most common reasons consumers present to a primary care provider resulting in healthcare expenditures in the US well over $100 billion annually. The 2012 Oregon Prescription Drug Monitoring Program annual report noted 20% of Oregonians, roughly 760,000, live with chronic pain with a goodly percentage being chronic low back pain. Paradoxically, the state of Oregon Evidence-based Low Back Pain Management Guidelines adopted by the state in October of 2011 recommend spinal manipulation as the only non-pharmacologic intervention for all three phases of low back pain; acute (0-4 wks.), subacute (4-8 wks.) and chronic (>8 wks.).
Chiropractic physicians are the best trained and skilled to perform spinal manipulation receiving between 800 and 1000 hours training in spinal biomechanics, physical examination of the spine, when and where to perform spinal manipulation, and counter-indications (when not to perform spinal manipulation). Additionally, chiropractic physicians as primary care providers are trained and skilled to differentially and correlatively diagnose consumers presenting with low back pain and rule out the occasional serious health condition (e.g. cancer) masquerading as simple mechanical low back pain, and make the appropriate referral for further lab tests or referral to the appropriate medical specialist.
Patients on the Oregon Health Plan are having trouble seeing a chiropractor because low back pain is below the prioritized list of covered diagnoses. Typically these patients have other conditions/diagnoses that are “above the line” such as Type II Diabetes which their medical primary care provider is treating. When these patients present with low back pain to their medical doctor they simply receive a prescription for pain mediation with their chief diagnosis remaining Type II Diabetes, not low back pain, and their doctor visit is paid for under the Oregon Health Plan.
Of great concern is the reality the myriad of various pain medications are far from benign and adding insult to injury. Acetaminophen (e.g. Tylenol) a typical first-line drug in a recent (July 25, 2014) Australian study published in the Lancet Medical Journal was shown to be no better than placebo. Acetaminophen is the leading cause of acute liver failure in the United States resulting in approximately 140,000 poisoning cases, 56,000 ER visits, and more than 100 deaths annually. Other first line medication non-steroidal anti-inflammatory drugs (NSAIDs, e.g., Advil), are currently the second leading cause of peptic ulcers resulting in more than 100,000 hospitalizations, at an estimated $2 billion in additional healthcare costs, and some 17,000 deaths each year.
It gets worse, Oregon is currently second in the nation for the most prescriptions for opioid narcotics per capita. Between 1997-2007 hydrocodone sales increased by 280%, oxycodone 866%, and methadone 1,293%, resulting in 700 poisoning deaths in that ten year period. Fifty three percent of all drug overdoses in Oregon are associated with prescription opioids, an overall increase of 540% since 1999 and a 1,500% increase in deaths from methadone alone. Prescription drug overdoses account for the most drug related deaths in Oregon, the opioid methadone being the leading cause and these deaths are occurring disproportionately within the Medicaid population.
In stark contrast as noted by the landmark Agency for Health Care Policy and Research, acute low back pain guidelines some 20 years ago (1994) and not refuted by any subsequent research or guidelines, chiropractic spinal manipulation both relieves pain and restores function while harmful pain medications relieve pain but do not restore function and result in substantial morbidity and mortality. But there is hope as Governor John Kitzhaber, MD, has stated often, “Oregon is choosing a different path.”
The Oregon Health Evidence Review Commission will be forming a task force to review the low back pain prioritized list lines with the goal of addressing this flaw resulting in Oregon Health Plan patient’s ability to receive drug free treatments such as chiropractic spinal manipulation. The task force will focus on evidence-based effective versus non-effective treatments for low back pain and none invasive spinal manipulation will be at the top the list of effective treatments. At the end of the day, Oregon Health Plan patients must have access to drug free evidence-based treatments such as chiropractic spinal manipulation, especially considering the state’s high incidence of morbidity and mortality related to pain medications which is partly why Governor Kitzhaber has proclaimed October as “Chiropractic Health and Wellness Month."
Vern Saboe, DC, DACAN, FICC, DABFP, DACO, FACO is a member of the Health Evidence Review Commissioner and Evidence-based Guidelines and Coverage Guidance Sub-committee.
