Association Between Chiropractic Spinal Manipulative Therapy and
Benzodiazepine Prescription in Patients with Radicular Low Back Pain:
A Retrospective Cohort Study Using Real-world Data from the USA
BMJ Open
June 13, 2022; Vol. 12; No. 6; Article e058769
Robert J Trager, Zachary A Cupler, Kayla J DeLano, Jaime A Perez, Jeffery A Dusek: from University Hospitals Cleveland Medical Center, Butler VA Health Care System (Pennsylvania), University of Pittsburgh School of Medicine, Case Western Reserve University School of Medicine (Ohio). This study cites 78 references.
“This is the first study to examine the association between CSMT [chiropractic spinal manipulative therapy] and subsequent BZD [benzodiazepine] prescription which was achieved through the use of a large, real-world database, for radicular low back pain (rLBP).”
There were 9,206 patients in each cohort, mean age of 38 years (range 18-49 years), and, 54% were male. Outcomes were measured at 3, 6 and 12 months.
“[The authors] hypothesise that adults receiving care for new diagnosis of rLBP with CSMT will have reduced odds of receiving a BZD prescription compared with those initiating care with a non-chiropractic provider over follow-up windows of 3, 6 and 12 months, which will be maintained after controlling for confounding variables.”
KEY POINTS FROM THIS ATICLE:
1) “[Both] chiropractic spinal manipulative therapy (CSMT) and prescription benzodiazepines are common treatments for radicular low back pain (rLBP).”
2) Benzodiazepines (BZDs):
- “Benzodiazepines (BZDs) are a class of psychoactive medication increasingly prescribed for patients with low back pain (LBP), and commonly used in patients with radicular LBP (rLBP), a subcategory of back pain with nerve root involvement.”
- “BZDs are sedative-hypnotic medications that act as central nervous system (CNS) depressants, and have anticonvulsant, anxiolytic and muscle relaxant properties.”
- “The number of physician visits during which BZDs was prescribed for back pain and chronic pain in the USA more than tripled from 2003 to 2015.”
- “In a 2018 survey, 27% of LBP patients reported being recommended BZDs by a medical doctor in the previous 12 months.”
- “There has not been conclusive evidence that BZDs produce an overall analgesic effect.”
3) Chiropractic
- “Chiropractors are portal-of-entry providers that treat a variety of musculoskeletal conditions, the most common of which is LBP.”
- Chiropractors use non-pharmacological treatments for patients with rLBP.
- “The most common treatment chiropractors employ is spinal manipulative therapy (SMT), also called chiropractic SMT (CSMT).”
- “SMTs include hands-on and instrumented-assisted therapies applied to the spine.”
- “In a 2019 survey, US chiropractors reported managing radiculopathy at least once per week, and being the first provider to diagnose radiculopathy in 74% of patients.”
- “[CSMT] include high-velocity, low-amplitude manipulation involving a thrust, and low-force, non-thrust or mobilization techniques.”
- “SMT may relax hypertonic (abnormally tight) muscles, or release adhesions surrounding the lumbar disc or facet joints, leading to improved range of motion in those with rLBP.”
4) “Previous research identified that patients receiving care with a chiropractor for incident LBP had reduced odds of receiving an opioid prescription compared with other provider types.” [Important]
- “Systematic reviews have found evidence supporting [SMT] treatment for acute, chronic and radicular LBP, while documenting its safety.”
5) Clinical Practice Guidelines (CPGs):
- “Like BZDs, opioids are prescribed for rLBP despite CPGs recommending their limited use.”
- “Insufficient evidence supporting the efficacy of BZDs for LBP and the risk of serious adverse events has led clinical practice guidelines (CPGs) to discourage their use for this condition.”
- “Recent CPGs from the National Institute for Health and Care Excellence (2020), Veterans Affairs and Department of Defense (2019), Global Spine Care Initiative (2018) and Belgian Health Care Knowledge Centre (2017) recommended against prescribing BZDs for LBP while those of the American College of Physicians (2017) concluded there was insufficient evidence for their effectiveness in acute or subacute LBP.”
6) “Adverse effects of BZDs include sedation, addiction and increased risk of suicide.”
- “Dependence occurs in 20%–100% of those taking BZDs for at least 1 month.”
- “There is an increased risk of fatal, accidental overdose with concurrent use of BZDs and opioids.”
- “BZDs are also a risk factor for motor vehicle collisions, falls and associated injuries, which may be explained by BZD-related psychomotor, balance and cognitive impairment.”
7) “Although BZDs are increasingly prescribed for LBP, there is no strong evidence supporting their use for this condition.” [Important]
8) Cohort:
- Subjects aged 18–49 with new rLBP were included.
- The most common cause of rLBP in patients less than 50 is lumbar disc herniation (LDH).
- Patients older than 50 with rLBP are often due to lumbar spinal stenosis (LSS) rather than lumbar disc herniation (LDH).
- Exclusions included serious pathology, structural deformity (spondylolisthesis and scoliosis), prior surgery, cauda equina syndrome, infection, stenosis of any spinal region, fracture or malignancy, and alternate neurological lesions causing LBP.
- Absolute contraindications to BZDs were glaucoma, chronic obstructive pulmonary disease, myasthenia gravis, Parkinson’s disease, porphyria, and pregnant or breastfeeding women.
9) “Radicular LBP is distinct from referred and axial forms of LBP, having a greater likelihood of pain radiating distal to the knee, neurologic deficits, neural tension and greater activity limitation.”
10) Conclusions
- “This study identified a significant reduction in odds of BZD prescription over 3-month, 6-month and 12-month follow-up windows in adults initiating care for rLBP with CSMT.”
- “These results reinforce the use of CSMT as a first-line non-pharmacological option for adults with rLBP.” [Key Point]
- The reduced odds of benzodiazepine prescription at 3 months was 44%, at 6 months it was 39%, and at 12 months it was 33%.
11) “These findings suggest that receiving CSMT for newly diagnosed rLBP is associated with reduced odds of receiving a benzodiazepine prescription during follow-up.”
COMMENTS FROM DAN MURPHY:
These studies show reduced opioids, gabapentin, and benzodiazepine prescriptions when chiropractic care is administered:
Article Review 20-18:
Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain and Use of Prescription Opioids
Article Review 48-18:
Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain
Article Review 15-19:
Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care
Article Review 48-19:
Observational Retrospective Study of the Initial Healthcare Provider for New-onset Low Back Pain with Early and Long-term Opioid Use
Article Review 49-19:
Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain
This article shows that the taking of either NSAIDs or steroids for acute back pain increases the risk of developing chronic back pain:
Article Review 7-23:
Acute Inflammatory Response Via Neutrophil Activation Protects Against the Development of Chronic Pain
