A National Disaster Opens the Door to Holistic Healthcare Strategies

It has only been in the past few years that the full repercussions of the country’s healthcare system being hijacked by several large drugmakers marketing opioids have become apparent. The resulting misuse and over-prescription of these powerful drugs are still causing profound misery for hundreds of thousands of people throughout the United States. It is also reshaping the American healthcare system itself, especially with regards to pain management, as the inherent dangers of opioids are realized and the need to find alternatives to them becomes an overriding priority.

The sins of the past are beginning to be dealt with via the court system. Companies like Purdue Pharma, Johnson & Johnson, Teva Pharmaceutical Industries, and several others have found themselves under scrutiny by many states’ attorneys general and federal prosecutors:

The investigation is part of a heightened law enforcement scrutiny around the country into companies that make and distribute prescription painkillers. Drug companies have faced criminal probes and multibillion-dollar lawsuits for their alleged role in the opioid epidemic.

This year, federal prosecutors in Manhattan and Cincinnati have brought novel cases against companies that distributed opioids to pharmacies, using criminal conspiracy charges typically deployed against drug dealers.

 These cases will be winding their way through courts for years to come. From a medical perspective, they represent a long-term effort that will eventually change for the better the overall healthcare matrix. But in the here and now, the priority is stopping the bleeding unleashed by the unethical actions of drug companies that created the opioid crisis - something that has severely harmed the nation.

But the over-prescription of opioids did not occur because there was not a need for what these drugs do - which is provide pain relief. Many people who became addicted to opioids were the victims of accidents, or disease, who were living with pain, sought treatment from medical professionals, and then found themselves falling into “that hole”:

It has only been in the past few years that the full repercussions of the country’s healthcare system being hijacked by several large drugmakers marketing opioids have become apparent. The resulting misuse and over-prescription of these powerful drugs are still causing profound misery for hundreds of thousands of people throughout the United States. It is also reshaping the American healthcare system itself, especially with regards to pain management, as the inherent dangers of opioids are realized and the need to find alternatives to them becomes an overriding priority.

The sins of the past are beginning to be dealt with via the court system. Companies like Purdue Pharma, Johnson & Johnson, Teva Pharmaceutical Industries, and several others have found themselves under scrutiny by many states’ attorneys general and federal prosecutors:

The investigation is part of a heightened law enforcement scrutiny around the country into companies that make and distribute prescription painkillers. Drug companies have faced criminal probes and multibillion-dollar lawsuits for their alleged role in the opioid epidemic.

This year, federal prosecutors in Manhattan and Cincinnati have brought novel cases against companies that distributed opioids to pharmacies, using criminal conspiracy charges typically deployed against drug dealers.

These cases will be winding their way through courts for years to come. From a medical perspective, they represent a long-term effort that will eventually change for the better the overall healthcare matrix. But in the here and now, the priority is stopping the bleeding unleashed by the unethical actions of drug companies that created the opioid crisis - something that has severely harmed the nation.

But the over-prescription of opioids did not occur because there was not a need for what these drugs do - which is provide pain relief. Many people who became addicted to opioids were the victims of accidents, or disease, who were living with pain, sought treatment from medical professionals, and then found themselves falling into “that hole”:

Paul Byrd has been in several car accidents. Those crashes left him with lasting injuries, including “lower back pains and mid back pains,” he said.

 

Byrd said that he “found relief in pain pills and opioids. It takes more and more to get there and get deeper in that hole.”

 

It didn't take long for Byrd to become hooked.

 

“Rely on these pills just to feel normal,” said Byrd.

For this man, chiropractic care was his way out of that hole. Accessing it is still more challenging than traditional treatments, but there’s more and more recognition that this situation needs to change.

That path led him to Dr. Patrick Ensminger:

 

“You see a lot more people saying I’m coming here because I don’t want drug-based care,” said Byrd.

 

While demand for his chiropractic care is surging, Ensminger said a limited number of patients can access his services.

 

“There exists significant insurance barriers to the public seeking pain management,” said Ensminger.

 

This, despite physician groups, the FDA and even the president's opioid cabinet touting this pain treatment option.

 

“We are attempting to create a sea change towards increased access to and coverage for chiropractic care,” said Ensminger.

 

A recent study in the medical journal BMJ shows patients who visited a chiropractor first decreased their odds of both early and long-term opioid use by 90%.

 

“That data hopefully will lead many medical physicians to begin increasing referrals to doctors of chiropractic and other drug-free care,” said Ensminger.

Curtailing the demand for opioids can be broken down into two broad categories, the first being the need to treat medical conditions in ways that curtail the amount of pain patients are dealing with and, secondly, treating pain that cannot be simply or quickly alleviated by treating the underlying condition causing it in ways that do not cause further complications. Both need to be dealt with in order to curtail the use of opioids. Increasing access to effective holistic treatments is increasingly on the nation’s to-do list.

Getting Opioids Out of the System

This situation has led to much research into ways to replace widespread opioid use in pain management. Before examining some of the holistic treatments that this process has embraced, let’s quickly look at how “we” got into the opioid crisis. It wasn’t by accident.

The Opioid Crisis: A Perfect Storm

One insidious aspect of the opioid crisis is that drugmakers used the vulnerability of individual patients to sell products that were inherently dangerous due to their long-term addictive qualities. But there was also an element of bad luck. This is because, by the time OxyContin - the springboard of the opioid crisis was first brought to market in 1996, the treatment of pain had finally been normalized in western medicine after decades of resistance.

For much of the rise of modern medicine, the pain of patients often didn’t even rise to being an afterthought. It was actively shrugged off and attempts to control it were resisted by much of the medical community:

… much of our understanding of pain pathophysiology is recent, and that the field remains in infancy but rapidly evolving. Before 1800, clinicians regarded pain as an existential phenomenon, a consequence of aging. There was no regulation on the use of cocaine and opioids, resulting in widespread marketing and prescribing for many ailments ranging from diarrhea to toothache. The Harrison Narcotic Control Act of 1914, passed in response to the sudden emergence of street heroin abuse as well as iatrogenic morphine dependence, influenced both physician and patient alike to avoid opiates. Patients with unexplained pain in the 1920s were regarded as deluded, malingering, or abusers, and cancer patients through the 1950s were encouraged to wean themselves off opioids until their lives “could be measured in weeks.”

The humane movement away from the position sought to develop ways to help patients deal with pain. This drove research and, eventually, the marketing of alternatives.

And one of the best alternatives was still opioids, which ironically enough already had a history of being abused. But they were also, from the perspective of drug companies operating in a for-profit marketplace, relatively easy and cheap to produce. And the marketplace for them was being primed:

The World Health Organization addressed the under-treatment of postoperative and cancer pain in 1986 with their Cancer Pain Monograph. A rapid improvement in the treatment of cancer pain soon unfurled in many countries … This further prompted a number of publications in the 1990s that questioned the state of pain under-treatment. Notably, Ronald Melzack in 1990 published an article in Scientific American that questioned why opioids were reserved solely for cancer pain and avoided entirely in chronic pain states. The newfound interest bore misconceptions, drawn largely by cancer pain specialists lacking expertise on other chronic, non-cancer pain, that equated the etiologies of malignant and non-malignant pain. This dangerous conflation disregards the complex biopsychosocial phenomena that is chronic pain, and despite many cautions to this effect, opioids grew into the primary modality of chronic non-cancer pain treatment in the USA.

Alongside this opioid evolution, the American Pain Society launched their influential “pain as the fifth vital sign” campaign in 1995, with intent to encourage proper, standardized evaluation and treatment of pain symptoms. The Veteran’s Health Administration lent support to the campaign with their 1999 adoption of pain as the fifth vital sign initiative.

Pain had long been pushed aside and the suffering of patients was not respected. It took a very long time for the medical profession to come to terms with this reality. It may have led it to also not scrutinize closely enough the first solution marketed to them and the floodgates may have been opened too quickly.

This unfortunately created a situation that made for easy pickings when Purdue Pharma, the maker of OxyContin, began to aggressively market its new product. It was not a great medical innovation by any means—opioids had been around for quite some time—which should have made its bold claims of not being addictive hard to swallow:

Prescriptions for opioids increased gradually throughout the 1980s and early 1990s. But it wasn’t until the mid-1990s, when pharmaceutical companies introduced new opioid-based products—and, in particular, OxyContin, a sustained-release formulation of a decades-old medication called oxycodone, manufactured by Purdue Pharma in Stamford, Connecticut—that such prescriptions surged and the use of opioids to treat chronic pain became widespread.

 

Purdue Pharma and other companies promoted their opioid products heavily. They lobbied lawmakers, sponsored continuing medical-education courses, funded professional and patient organizations and sent representatives to visit individual doctors. During all of these activities, they emphasized the safety, efficacy and low potential for addiction of prescription opioids.

In hindsight, the ease with which Purdue Pharma was able to reconfigure pain management in the U.S. healthcare system is both impressive and disturbing. Lowered levels of federal drug regulation, the repercussions of ending the ban on the direct-to-consumer advertising (DTCA) of drugs, and a sincere recognition of the need to take pain management more seriously all conspired to make Purdue’s efforts wildly succeed.

            And the company’s efforts were not insubstantial. It made a major commitment to selling its product, which meant selling doctors on prescribing it:

From 1996 to 2001, Purdue conducted more than 40 national pain-management and speaker-training conferences at resorts in Florida, Arizona, and California. More than 5000 physicians, pharmacists, and nurses attended these all-expenses-paid symposia, where they were recruited and trained for Purdue's national speaker bureau …

 

One of the cornerstones of Purdue's marketing plan was the use of sophisticated marketing data to influence physicians’ prescribing. Drug companies compile prescriber profiles on individual physicians—detailing the prescribing patterns of physicians nationwide—in an effort to influence doctors’ prescribing habits. Through these profiles, a drug company can identify the highest and lowest prescribers of particular drugs in a single zip code, county, state, or the entire country …

 

A lucrative bonus system encouraged sales representatives to increase sales of OxyContin in their territories, resulting in a large number of visits to physicians with high rates of opioid prescriptions, as well as a multifaceted information campaign aimed at them. In 2001, in addition to the average sales representative's annual salary of $55,000, annual bonuses averaged $71,500, with a range of $15,000 to nearly $240,000. Purdue paid $40 million in sales incentive bonuses to its sales representatives that year.

And that was just the marketing outlay for one drug. During the late 1990s and the first decade of the 21st century, several more—and even more powerful—opioids hit the market. The pain management sector was flooded with opioids and overall sales skyrocketed.

            And the sad irony of this takeover of pain management, which eventually led to a subsequent rapid expansion of black market consumption of opioids like heroin and fentanyl, is that it became apparent fairly quickly that opioids aren’t even that great for managing pain and were already known to be addictive:

In fact, opioids are not particularly effective for treating chronic pain; with long-term use, people can develop tolerance to the drugs and even become more sensitive to pain. And the claim that OxyContin was less addictive than other opioid painkillers was untrue—Purdue Pharma knew that it was addictive, as it admitted in a 2007 lawsuit that resulted in a US$635 million fine for the company. But doctors and patients were unaware of that at the time.

This has left the medical establishment not only needing to develop other ways to manage pain but also effective ways to treat opioid addiction. A bad situation was made considerably worse.

One Way Out: The Efficacy Of Holistic Treatments

There are a number of new approaches being developed to try to replace the bloated role that opioids came to play in pain management. Some are other types of drug therapies, such as oral analgesics, topical analgesics, and a range of muscle relaxers and nerve blocks. But another area of development is alternative therapies.

This is driven by an increasing body of research that shows such holistic treatments can help many patients manage - or even avoid - chronic pain. As the Director of the Comprehensive Pain and Headache Center at The Ohio State University Wexner Medical Center’s Neurological Institute, Dr. Steven Severyn stated in U.S. News & World Report: “…opioids have long been considered the ‘go-to’ drugs to help manage acute pain … [but] Various studies have shown the benefits of using non-drug treatments such as acupuncture, aromatherapy, biofeedback, chiropractic, cognitive behavioral therapy, hypnotherapy and massage to help relieve chronic pain.”

One key aspect of holistic treatments is that the patient is approached as a whole being, as opposed to issues being treated in isolation, which increases the likelihood of specific aspects of a person’s condition receiving management without due consideration of possible repercussions. One aspect of the opioid disaster is that pain was treated in a vacuum, with an attitude of “have a bottle of these pills and take them until it doesn’t hurt anymore” becoming normalized. This approach often did not carefully consider the precise source of the pain nor seriously appreciate the possibility of an addiction developing due to either physiological or psychological issues. The guiding principle of the Western medical tradition—primum non nocere (first, do no harm)—was profoundly discarded.

The fact is that holistic treatments are becoming more normalized as they are backed by more data. Take chiropractic care, for example. It has, over the past several decades, slowly come to be appreciated as an effective treatment for many musculoskeletal issues, including back or neck pain or repetitive-motion injuries. Rather than simply putting a drug Band-Aid over the pain being caused by a chronic condition, chiropractic care is part of a multipronged approach to health:

The 2017 Canadian Guideline for Opioid Therapy and Chronic Non-Cancer pain recommends the optimization of non-opioid medication and non-drug therapy. This includes health care provided by chiropractors and other professionals who treat back, neck, and shoulder pain, before considering opioids.

 

Translation: back pain is best managed by a team approach to care, with the team consisting of a chiropractor, family doctor or nurse practitioner, and others such as a physiotherapist and registered massage therapist. Professionals aware of these current clinical guidelines, who are open to collaborating or even better, have existing professional relationships to help co-ordinate your care, will serve you well. You should be wary of clinicians who discourage collaboration.

One of the reasons it was so easy to sell opioids is that it was easy to market them as being a “magic bullet” that could make the treatment of pain relatively simple and easy to manage. If only life were that simple. The human body, and the people who inhabit them, are complicated and highly variable. Embracing that fact, while avoiding relying on approaches that are powerful in large part due to their simplicity (and which can oftentimes be marketed at a high-profit margin), may very well be far wiser over the long-term.

            Managing pain is far more complicated than once assumed and it demands solutions that appreciate the complexity of the task at hand. This is an ongoing process currently driven by the extreme need to curtail the use of opioids. They have obviously proven to have severe side effects, not only for individual patients, but for society as a whole, with the opioid crisis now causing severe societal hardships in communities all across the United States. Developing a more complex understanding of pain management is an area that has been seeing, on the margins, increased interest from some in the medical community over the same time period as opioids became a crutch for many people:

Complementary and alternative healthcare and medical practices (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. The list of practices that are considered as CAM changes continually as CAM practices and therapies that are proven safe and effective become accepted as the “mainstream” healthcare practices. Today, CAM practices may be grouped within five major domains: alternative medical systems, mind-body interventions, biologically-based treatments, manipulative and body-based methods and energy therapies.

These areas, also referred to collectively as holistic treatment, are rooted in the idea that treating the whole person requires an understanding of not only their medical situation, but also their emotional and social environments. Ultimately this will lead to treatments better tailored to their situation:

Basic principles of integrative medicine include a partnership between the patient and the practitioner in the healing process, the appropriate use of conventional and alternative methods to facilitate the body’s innate healing response, the consideration of all factors that influence health, wellness and disease, including mind, spirit and community as well as body, a philosophy that neither rejects conventional medicine nor accepts alternative medicine uncritically, recognition that good medicine should be based in good science, inquiry driven and open to new paradigms, the use of natural, less invasive interventions whenever possible, the broader concepts of promotion of health and the prevention of illness as well as the treatment of disease. Studies are underway to determine the safety and usefulness of many CAM practices. As research continues, many of the answers about whether these treatments are safe or effective will become clearer.

The need to curtail the use of opioids to treat pain makes this expansion of medical thinking well-timed. It’s becoming clear that some of the decline in the prescription of opioids is due to the efficacy of holistic treatments.

            This has resulted in the expansion of alternative care strategies continuing not only with regards to underlying conditions, such as back and neck injuries, but also to directly treat pain and the now firmly established opioid use disorder (OUD) that has been left in the wake of over-prescription of these drugs.

Treating Underlying Conditions

As already stated, the expansion of alternative medicine was ironically enough occurring at the same time as opioid use was exploding on the medical scene. The openness with new approaches was not without critics and there were growing pains, but during the 1990s a wide range of holistic treatments were making their way onto the medical radar screen and being examined:

Enough Americans had similar interests that, in the early 1990s, Congress established an Office of Alternative Medicine within the National Institutes of Health [NIH]. Seven years later, that office expanded into the National Center for Complementary and Alternative Medicine (NCCAM), with a $50 million budget dedicated to studying just about every treatment that didn’t involve pharmaceuticals or surgery—traditional systems like Ayurveda and acupuncture along with more esoteric things like homeopathy and energy healing.

Through fits and starts this process has continued over the past two decades, with the process of fine-tuning and learning being captured to some extent with the federal government dropping the “alternative” tag and changing the name of NIH’s office to the National Center for Complementary and Integrative Health (NCCIH). This represents the mainstreaming of some aspects of holistic treatments and an altering of what falls under the “normal” parameters of modern medicine:

There are 50 institutions around the country that have integrative in their name, at places like Harvard, Stanford, Duke, and the Mayo Clinic. Most of them offer treatments like acupuncture, massage, and nutrition counseling, along with conventional drugs and surgery.

 

The actual treatments they use vary, but what ties integrative doctors together is their focus on chronic disease and their effort to create an abstract condition called wellness. In the process, they’re scrutinizing many therapies that were once considered alternative, subjecting them to the scientific method and then using them the same way they’d incorporate any other evidence-based medicine.

 

This approach is forcing the entire medical community to grapple with certain questions: How has the role of a doctor changed over the years? Are there better ways to treat the kinds of health problems that can usually only be managed, not cured? And how do you gather evidence on therapies that involve not only the body but also the mind?

 

These questions—and the evolving answers to them—has led to several once “alternative” approaches becoming incorporated into routine medical practice in some areas. This is especially true of chiropractic care, which is increasingly becoming part of treating a wide range of conditions. It is even becoming more common for chiropractors to have their offices co-located with other medical practices.

There are more and more case studies supporting this holistic approach. Here is one from an article entitled “Chiropractors and Collaborative Care: An Overview Illustrated with a Case Report,” which describes the treatment of a patient that involved a family physician, mental health counselor, anxiety treatment and research center, nurse practitioner, and chiropractor:

Prior to a diagnosis of CTTH [chronic tension-type headache], a 44-year old female was referred by her family physician to a mental health counselor with concerns of anxiety attacks. She complained of anxiety attacks on a daily basis with heart palpitations, nausea, increase in perspiration, and dizziness. She was prescribed an antidepressant but stopped the medication after one month because of unwanted side effects...

On examination, the chiropractor noted sub-occipital and trapezius muscular pain and tightness. Active and passive ranges of motion were decreased in flexion and bilateral lateral flexion and rotation. The patient reiterated her insomnia, recurrent sinus infections and ongoing daily headaches.

 

In this multidisciplinary care setting, it is commonplace for hallway consultations to occur on mutual patients. These consultations are often triggered by review of the electronic medical record (EMR) to determine common benefits of concurrent care. Thus further discussions by the chiropractor with the counselor and with the patient indicated that the muscular pain, tension and headaches acted as a threshold trigger for the patient’s panic attacks. The patient was hoping the care would offer a way to teach her how to control her pain.

 

A secondary diagnosis of CTTH was made by the chiropractor in this case to quantify the pain-related headache symptoms. To this point her other care providers had only managed the anxiety disorder, as providing a headache diagnosis is typically out the scope of practice of non-medical providers in this setting. Previous authors have noted that co-morbid headaches are common with anxiety disorders reflecting the burden of the disease …

 

In this instance, the additive approach was a consistent message to the patient from the counselor and chiropractor at periodic visits, and confirmed in the EMR, on the linkage between stress and neck pain with encouragement of neck stretching during times of anticipated stress to elicit a sustained behaviour change in the patient.

 

As a result of this multidisciplinary intervention of CBT and manual therapy spanning 4 months, the patient reported a return to gainful work. She also reported a cessation of medications through the support of her family physician … The patient also reported as part of the subjective portion of her re-assessment that both her depressive and anxiety symptoms that were present over the last 20 years were now under control, yet she still experiences pain. She described that the collaborative care she received appeared to increase the threshold for the trigger of her CTTH and panic attacks thereby improving her ability to sustain her activities of regular work.

Such collaborative works that introduce nontraditional modalities like chiropractic care into routine healthcare decision-making are helping to alleviate debilitating conditions for patients, lessening not only pain but also increasing overall health outcomes.

Treating Pain

The current crisis in pain management—brought on in large part by the need to curtail opioids that both many patients and the medical establishment as a whole became addicted to—is driving the expansion of holistic treatments to curtail the need for drug-based pain management. This is now an approach being embraced by mainstream power brokers of the medical field like the Association of American Medical Colleges (AAMC):

As the opioid epidemic rages on, medical educators and researchers are increasingly exploring nonpharmacological treatments for pain.


When patients with chronic pain visit Erica Kumala, MD, at the Family Medicine Clinic at Alvernon, they likely won’t leave with an opioid prescription. Rather, the second-year resident in the University of Arizona—Tucson Alvernon Family Medicine Residency program may recommend they try a supplement like magnesium or refer them to a local yoga class as part of their treatment plan.

 

Kumala is part of a group of medical residents who are receiving specialized training through the University of Arizona Center for Integrative Medicine, which involves instruction in how to care for patients suffering from chronic pain with reductions in or without the use of opioids.

 

The training can’t come soon enough. As opioid misuse, addiction, and overdose reach historic proportions, medical schools across the country are incorporating training in nonpharmacological treatment options into their curriculums. Major research laboratories are also devoting time and resources to exploring the efficacy of integrative therapies.

Given the prevalence of chronic pain in modern culture—driven by a wide range of causes, from sedentary lifestyles to the increasing survival rates of cancer patients—the need to develop consistent strategies to treat it while not introducing a dependence on addictive drugs is paramount.

This is why there is an open effort to not only undertake more research but also quickly integrate successful treatments into the medical mainstream. Any non-drug treatment that can either treat painful conditions or lessen existing pain cuts down on the demand for the opioids that have proven to be Pandora’s box of unintended consequences. The need for more tools is acute:

Low back pain is no small matter, with 80% of adults experiencing the affliction at some point in their lives. It’s also bound up in the opioid epidemic, with many people turning to opioids to alleviate their suffering.

 

“Most people … are treated with opioids, and that’s certainly not the best way to start with the treatment of chronic low back pain,” says [David] Shurtleff [deputy director at the NCCIH].

 

As part of the NIH Back Pain Research Consortium (NIH BACPAC), the National Center for Complementary and Integrative Health is focusing on the mind and body mechanisms of back pain and complementary therapies for treatment.

 

The agency is also collaborating with the Centers for Medicare and Medicaid Services (CMS) on a clinical trial of acupuncture involving older adults in real-world settings.

 

The NIH BACPAC trial may have important implications for health care, as its success could lead to more insurance coverage for complementary and integrative therapies.

 

“If that study proves positive, then there’s a path forward for CMS to allow reimbursement for acupuncture for the treatment of lower back pain,” making it a potential “game-changer,” says Shurtleff.

The management of pain is not only one of the fastest-growing areas of medicine but also an area in which holistic treatments are being taken seriously and incorporated into care strategies. This process will lead to a more integrated healthcare system that provides patients with a wider range of options.

            It is already clear that chiropractic care is one of those options and that it is extremely effective in treating pain stemming from certain chronic conditions. Other holistic treatments are also finding their way into treatment modalities.

Treating Opioid Use Disorder

A hopefully short-term issue of deep importance is helping people who have become addicted to opioids—with the gateway sadly oftentimes being their having followed the advice of their physician—overcome their addictions. Holistic treatments are proving to be a strategy that is working for at least some people dealing with opioid addiction:

In a series of studies, an eight-week course in mindfulness techniques appeared to loosen the grip of addiction in people who had been taking prescription painkillers for years and experienced powerful cravings for the drugs.

 

Compared to research subjects who discussed their pain and opioid use in group sessions for eight weeks, those who focused on their breathing, bodily sensations and emotions showed evidence of reduced drug-craving and greater control over those powerful impulses.

 

The brains of subjects who got mindfulness training also evinced a renewal of pleasure in people, places and things that typically falls away as addiction takes hold. The brain activity of those who attended group sessions showed no evidence of having recaptured a sense of joy in life’s positive offerings.

This is just one example of widening the concept of pain from simply an isolated physical sensation to one that embraces other aspects of being and the plasticity of the brain to provide better outcomes. It requires a deeper commitment of time and depends on practitioners as opposed to drug therapies to deliver results that are more likely to be enduring and do not include the risk addiction that can unleash a profound litany of side effects both medical and social.

            Acupuncture is also a technique that is subject to increasing research in treating opioid addiction. The ancient Chinese branch of medicine—whose core foundation is the belief that treatment of the mind and body are inextricably linked—appears to have a positive effect on dopamine regulation in the brain, which is one of the key factors in addiction:

Chronic exposure to drugs of abuse produces a withdrawal state as reflected in increases in brain reward thresholds, and this change in reward threshold appears to be opposite to actions of the drug administered acutely. These opposite proponent and opponent processes during the development of drug addiction may contribute to the intense drug craving experienced by addicts. Based largely on animal self-administration, the reinforcing effects of drugs have been linked to central dopamine activity in the mesolimbic dopamine system. While little is known about the basic mechanism of acupuncture in treating drug addiction, the neurochemical and behavioral data reviewed earlier showed that acupuncture directly or indirectly affects the mesolimbic dopamine system. These results suggest that acupuncture helps to maintain the homeostasis and balance between positive and negative processes involved in drug addiction. Moreover, in a more general sense, these results suggest that acupuncture can be used as a therapeutic intervention for correcting reversible malfunction of the body by directing brain pathways and thus contributes to balance in the central nervous system by regulating neurotransmitters.

Continued research of acupuncture as a treatment option for OUD is built on the increasing acceptance of the technique in other areas. For example, in a January 21, 2020, press release the Centers for Medicare and Medicaid Services (CMS) announced acupuncture services would be covered by Medicare for individuals with chronic back pain. Steps like these are proof that holistic treatment options are gaining more acceptance and, therefore, steps to make them more accessible are being taken.

The U.S. Military Enlists Chiropractic Care

Aspects of the wide array of holistic treatments being explored in the general healthcare system in the United States may, in some cases, be even more robust in its military. Given the large number of service members and veterans who are dealing with long-term health issues stemming from service in the wars in Afghanistan and Iraq—or just the general wear and tear of military life—the military medical system is also looking for solutions. Chronic pain is as prevalent, if not more so, in the military as in civilian life and it has been found that rates of “… prescription opioid misuse are higher among service members than among civilians.”

The Military Seeks Solutions

Following the same approximate timeline as the CMS, in late 2019 the Defense Health Agency (DHA)—which integrates the operations of the Army, Navy, and Air Force medical services—announced that “in the coming months” chiropractic and acupuncture care may become available under the Tricare system that serves the nation’s military personnel and their dependents. This comes on the heels of a large, long-term study that examined the efficacy of chiropractic care and ultimately found that is was: “… deemed by a Defense Department assessment to mitigate lower back pain (LBP) and subsequently improve fitness among U.S. service members. Much of the military’s focus has been on lower back pain because it is a very common cause of disability for U.S. troops.

            The $7.5 million report included three clinical trials spanning a decade that were part of the 2010 National Defense Authorization Act, one aspect of which was coming to terms with the long-term fallout of extended combat missions by U.S. troops in the Middle East:

The first clinical trial, to determine whether chiropractic care reduced pain and helped troops stop smoking, showed statistically significant improvement for service members with back pain who received chiropractic care alongside regular medical care.

 

The second trial, to test whether chiropractic care had any effect on the reaction and response times of special operations troops, showed that a single session had an immediate effect on motor response.

 

But the trials also found that chiropractic care had no real influence on smoking cessation, nor did the acceleration of response time among special operators last after the initial effect.

 

The third trial—on whether chiropractic care improves fitness among troops with back pain—showed that those who received such care saw a 5% increase in isometric strength, as opposed to a 6% decrease in strength among the control group, made up of service members who also had lower back pain but didn't receive chiropractic care.

 

Given the significance of lower back issues in military personnel and the evident effectiveness of chiropractic treatments, it seems apparent that such therapy is well on its way to becoming routine within the military.

The move to expand access to chiropractic care has begun to be codified. In late 2018, “The Chiropractic Health Parity for Military Beneficiaries Act” (S. 3620) was introduced by Democratic Wisconsin Senator Tammy Baldwin and Republican Kansas Senator Jerry Moran. Currently still in committee, the bill seeks to expand access to the kinds of treatments that have now been found advantageous to both troops and the military’s overall readiness. The Senate bill would:

… not only enable those who currently receive chiropractic care to continue their treatment, but would also establish, in the wake of the nationwide opioid crisis, an important non-drug option for pain management in the TRICARE program.

 

“Chiropractors have become valued members of the military healthcare team. Their non-drug, non-addictive and noninvasive approach to pain management is particularly relevant today for military personnel who wish to avoid the risk of addiction from prescription opioid pain medications,” said ACA [American Chiropractic Association] President N. Ray Tuck Jr. “This latest legislation would ensure that military retirees as well as members of the National Guard and Reserve utilizing the TRICARE system continue to have access to the same quality chiropractic care for their pain.”

 Chiropractic services were first made available to active-duty military personnel following the enactment in 2000 of legislation creating a permanent chiropractic benefit within the Department of Defense health care system. As part of the benefit’s pilot program, before full implementation, retirees were also granted access to chiropractic services on a space-available basis. The benefit was valued within the TRICARE community at the time. Today, however, chiropractic care is available only to active-duty service members at more than 60 military treatment facilities in the United States, as well as bases in Germany and Japan.

This move towards expanding chiropractic care for service members is growing in strength because of the consistent findings of not only the three studies that were part of the 2010 National Defense Authorization Act but others focused on lower back pain as well:

Since LBP is one of the leading causes of disability among U.S. military personnel, it is important to find pragmatic and conservative treatments that will not only treat LBP, but could ultimately preserve low back function so that military readiness is maintained … A pilot study compared chiropractic care plus standard medical care with standard medical care alone for active duty military personnel with acute LBP. Improvements in pain and disability were significantly greater in the chiropractic care group.

It is consistent findings on the success of chiropractic care within military parameters that is leading to the expanding embrace of such care by the Department of Defense. As with other transformations in American life—such as integration, when President Truman issues Executive Order 9981 in 1948 abolishing racial segregation in the military—the military finds itself on the leading edge of change.

Civilian Medicine Is Moving In the Same Direction

These studies focused on the efficacy of chiropractic care for military personnel are only amplifying similar findings—over the same time period that saw the rise of opioids— in civilian settings. This is why chiropractic care is on the cusp of becoming mainstream medicine, which will continue to expand its use:

“Chiropractic was the original holistic medicine in that it focused on treating the whole person, not just the body part that hurt,” says Michael Schneider, an associate professor of health sciences at the University of Pittsburgh. His research on chiropractic suggests that cervical and lumbar manipulation—the back and neck adjustments most people associate with a visit to a chiropractor—can be an effective treatment for low back pain. A study published in April 2017 in the Journal of the American Medical Association supported this, finding that based on the latest research, spinal manipulation can modestly reduce a person’s lower back pain.

 

Chiropractic manipulation also often leads to better patient outcomes, especially when combined with standard medical care, other studies suggest.

 

“The benefits of chiropractic for acute low back pain have been pretty widely accepted for years now within the medical community,” says Dr. Ronald Glick, assistant professor of psychiatry, physical medicine and rehabilitation at the University of Pittsburgh School of Medicine and coauthor of several of Schneider’s research papers. “When I started in practice over 30 years ago, people would look askance at a physician who recommended chiropractic, but that’s not the case anymore,” he adds.

This continued mainstreaming of chiropractic care—which may very likely continue to open the door to other forms of holistic treatments—is ongoing and appears to “have the wind” at its back.

            Given the ongoing potency of the opioid crisis—with over 67,000 overdose deaths in 2018, a slight decrease from the 70,000 in 2017—it is still abundantly clear that alternative methods of treatment, strategies for pain management, and ways to manage the ongoing opioid addictions of hundreds of thousands of people are vital moving forward. The opioid wave may—or may not—have crested, but the situation is still grim:

The opioid epidemic began in the 1990s, as the proliferation of opioid painkillers—not just for patients but among teens rummaging through their parents’ medicine cabinets, friends and family, and the black market—led to a spike in opioid addiction and overdoses. That first wave was followed by two others as drug cartels capitalized on the rise of addiction, through first the rise of cheap, potent heroin and then the spread of even cheaper and more potent fentanyl. With each of the three waves of the opioid epidemic, addiction cases and overdose deaths increased.

 

The CDC numbers suggest that, for the first time in three decades, the opioid crisis may be getting better. But overdose deaths remain historically high—and there are red flags in the data that should invite caution before anyone declares victory over the opioid epidemic.

Luckily, a number of holistic treatment strategies are not only available but are also becoming more accepted and available. They appear to be an important and vital aspect of dealing with the disaster that is the opioid crisis and a way to bring more diverse and effective healthcare options to people throughout the United States.