Valley News Staff Writer
Lebanon — Researchers at Dartmouth-Hitchcock and the Geisel School of Medicine are highlighting a study that found that New Hampshire patients who received chiropractic care for lower back pain are significantly less likely to fill a prescription for an opioid than patients who didn’t see a chiropractor.
As a result, the Dartmouth researchers, among others, are pushing for expanding insurance coverage for chiropractic care.
The findings, which were published earlier this year in The Journal of Alternative and Complementary Medicine, further bolster guidelines from groups such as the American College of Physicians, which suggest that physicians should first treat patients suffering from lower back pain with therapies such as spinal manipulation, a common chiropractic treatment, before prescribing opioids.
Expanding access to such therapies — which are not always covered by health insurance — was the subject of a discussion some of the researchers had on Tuesday with David Mara, who serves as New Hampshire Gov. Chris Sununu’s adviser on addiction and behavioral health, at Dartmouth-Hitchcock Heater Road.
“I believe it’s all about access and if there are other options to pain medication it should be available to citizens of New Hampshire,” Mara said to reporters following the meeting.
He noted that some patients in New Hampshire have health insurance that covers chiropractic care, while others do not.
“We’re trying to do anything we can to stop more people from suffering from addiction,” Mara said.
Changing the way providers treat lower back pain has the potential to make a difference in overall opioid use, given that 59 percent of U.S. adults prescribed opioids reported having back pain, according to a 2008 study in the Journal of Pain and Symptom Management.
The study’s authors — James Whedon, director of health services research at the Southern California University of Health Sciences; Andrew Toler, an epidemiologist formerly of the Dartmouth Institute for Health Policy & Clinical Practice; Justin Goehl, a D-H chiropractor and Geisel clinical assistant professor; and Dr. Louis Kazal, a D-H family medicine doctor and a Geisel associate professor — conducted their study using insurance claims data for New Hampshire adults enrolled in a health plan for 2013 and 2014, with at least two clinical office visits within 90 days for a primary diagnosis of lower back pain in 2013. They excluded patients with a diagnosis of cancer in 2013 or 2014.
Of that group, nearly 6,900 patients with lower back pain had received care from a chiropractor and about 6,500 had not. Of those who did get chiropractic care, 19 percent filled a prescription for an opioid. Of those who did not, 35 percent filled such a prescription. Overall, the researchers found that those who received chiropractic care were 55 percent less likely to fill an opioid prescription than those who did not.
At the same time, however, the authors found that the cost per person in 2013 for filling opioid prescriptions for those who received chiropractic care was 74 percent lower than for the patients who didn’t see a chiropractor.
And the per-person cost for office visits in 2013 was 78 percent lower for those who had received chiropractic care than for those who had not.
Though the study points to a potential relationship between chiropractic care and opioid use, it does not define that relationship. As the study notes, it may be that people who receive chiropractic care already are biased against opioids.
“Recipients of services provided by doctors of chiropractic may differ from nonrecipients with regard to beliefs, attitudes, and predisposition to use prescription medications,” the authors wrote in the study.
It’s also unclear what element of the treatment offered by chiropractors — spinal manipulation or recommendations about diet and exercise, for example — might make the difference.
But Whedon said the remaining unknowns should not prevent providers from expanding access to chiropractic care.
“It’s a possible partial solution to the opioid crisis,” he said. “The data points to that possibility. We can’t always wait for conclusive causal evidence nailed down by gold-standard clinical trials in order to explore alternatives to what we’ve got.”
Whedon said chiropractic therapy is “actually scientifically mainstream.”
The reasons it hasn’t been totally integrated into the health system have more to do with culture and sociology, he said.
“If therapies are effective and safe patients and patients want them, they should have access to them,” he said.
Informed by research like the recent study, Mark Stagnone, president of the New Hampshire Chiropractic Association who also attended Tuesday’s meeting in Lebanon, said he hopes insurers may be convinced to expand coverage of chiropractic care and other therapies such as acupuncture and massage that may also help to reduce opioid use.
“I’ve known my entire (32-year) career that chiropractic is a great means for people to become well without the use of any drugs really,” said Stagnone, who practices in Londonderry, N.H.
It’s only now that the state and the country are in the midst of an opioid epidemic that a broader audience has started to take notice, he said.
Even when health insurance does cover chiropractic treatment, Stagnone said the co-pays — which can be as high as $60 per visit — can discourage patients from using it.
“There’s a bias that exists,” he said. “We’re just trying to get that bias removed.”
Pointing to the reductions in cost the study’s authors found, Stagnone said, “We’ll actually see a savings as well. We’re very affordable.”
Over the past year and a half, D-H has added a chiropractor to its primary care clinic on Heater Road, said Kazal, one of the study’s authors. In that role, Goehl, another author, has become part of the care team, working in conjunction with doctors, nurse practitioners and physician assistants.
“This is giving us more options,” Kazal said.
When Goehl works with patients, other providers can observe his techniques and their effects.
Even so, to keep the books balanced and ensure that Goehl’s services continue to be available to patients, Kazal said he hopes to convince insurers to cover chiropractic care at a sufficient rate.
“Things are always limited by access that’s determined by insurance and reimbursement,” Kazal said. “…One of the hopes with this paper and what’s happened today is that we can change that.”