Chiropractic Spinal Manipulation for Sciatica and Opioid-related Adverse Events

Association Between Chiropractic Spinal Manipulation for Sciatica and Opioid-related Adverse Events:
A Retrospective Cohort Study

PLoS ONE

January 28, 2025; Vol. 20; No. 1; Article e0317663

Robert J. Trager, Zachary A. Cupler, Roshini Srinivasan, Elleson G. Harper, Jaime A. Perez; from University Hospitals Cleveland Medical Center; School of Medicine, Case Western Reserve University; Duke University School of Medicine; Butler VA Health Care System, Butler, Pennsylvania; University of Pittsburgh School of Medicine. This study cites 49 references.

ORADEs = Opioid Related Adverse Drug Events
CSM = Chiropractic Spinal Manipulation

Patients were divided into two cohorts of 372,471 subjects each with a 1-year follow-up:

• CSM
• Usual medical care

The authors hypothesize that adults receiving CSM for sciatica will have a reduced risk of opioid-related adverse drug events (ORADEs) over a one-year follow-up compared to matched controls not receiving CSM.

Patients were adults of at least age 18 years with their first occurrence of sciatica or lumbosacral radiculopathy.

KEY POINTS FROM THIS ARTICLE:

1) “Opioids are narcotic analgesic medications that are often used to treat painful conditions such as sciatica, a radiating pain from the lumbar spine into the lower extremity most often caused by irritation of lumbosacral nerve root(s).”

• “Despite limited evidence of efficacy in this condition, opioids are frequently prescribed to treat sciatica.”
• “Opioids may cause a range of adverse effects commonly including constipation, dizziness, and sedation, and less often, nausea and vomiting.”
  • “Opioids have the potential for misuse, long-term use, dependency, addiction, and respiratory depression leading to death.”
• “Opioid related adverse drug events (ORADEs) are typically defined as moderate to severe adverse effects, such as opioid-related poisoning, overdose, and death.”
• “The yearly incidence of opioid overdose deaths in the US has gradually increased over the past two decades.”

2) “Chiropractic spinal manipulation is a form of manual therapy directed to the joints of the spine.”

• “Given its clinical effectiveness for treating sciatica, [chiropractic] is recommended by clinical practice guidelines for treatment of this condition.”
• “Prior studies suggest that receiving CSM for spinal pain is associated with lower rates of opioid prescription compared to usual medical care and potentially reduces risk of any adverse drug event compared to conventional medical management in adults.”
• “[Historically], patients receiving chiropractic spinal manipulation (CSM) for spinal pain are less likely to be prescribed opioids, and some evidence suggests that these patients have a lower risk of any type of adverse drug event.”

3) “The United States’ (US) Centers for Disease Control (CDC) and several recent clinical practice guidelines have discouraged prescribing opioids for acute musculoskeletal etiologies of low back pain.”

4) Findings:

• “The incidence of ORADEs over one year following the index date in adults with sciatica was lower in the CSM cohort compared to the usual medical care cohort,” by 32%. [Key Point]
• “Our novel finding of reduced risk of an ORADE among CSM recipients builds upon the prior literature on this topic.”
• “A consistent theme has emerged whereby patients initially receiving CSM for low back pain are less likely to have an adverse drug event.”

5) Conclusions:

• “The present study supports our hypothesis that among adults with a new diagnosis of sciatica, initially receiving CSM is associated with a reduced risk of an ORADE over a one-year follow-up compared to matched controls not initially receiving CSM.” [Key Point]
• “This study found that adults with sciatica who initially received CSM had a lower risk of an ORADE compared to matched controls not initially receiving CSM, likely explained by a lower probability of opioid prescription.”
• “These findings corroborate existing practice guidelines which recommend adding CSM to the management of sciatica when appropriately indicated.”
• “Adults with a new diagnosis of sciatica who initially received CSM had a significantly lower risk of ORADEs over 1-year follow-up compared to matched controls initially receiving usual medical care.”
• “[This] study builds on previous evidence to suggest that among those with spinal pain, upstream exposure to CSM may influence downstream use of opioids.”
• “The present findings suggest that CSM has value in terms of potential mitigation of ORADEs among those with sciatica and reinforces recommendations of previous guidelines to consider the use of CSM alongside other therapies for this condition.”

6) “As CSM is already recommended by several clinical practice guidelines for sciatica to be used in conjunction with other therapies (e.g., exercise), clinicians may consider CSM in appropriate clinical contexts (e.g., patient preference for CSM; lack of contraindications such as spinal infection, structural instability, or cauda equina syndrome).”

7) “Strengths of this study include an interdisciplinary author team, controlling for prior opioid prescriptions and other relevant ORADE risk factors, examination of adverse events specific to opioids, large sample size of 744,942 total patients, detailed selection criteria, and relatively long follow-up window.”

We have reviewed these studies related to chiropractic care and sciatica/leg pain:

Article Review 3-1:
Conservative Treatment of Intervertebral Disk Lesions

Article Review 4-10
Reduction of Lumbar Disc Prolapse by Manipulation

Article Review 5-10
Treatment of Lumbar Intervertebral Disc Protrusions by Manipulation

Article Review 27-15
Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion

Article Review 31-15
Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging–Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low-Amplitude, Spinal Manipulative Therapy

Article Review 25-17
Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain

Article Review 40-17
Low Back Pain and Pain Resulting From Lumbar Spine Conditions

Article Review 1-18
Manipulation in Back Pain

Article Review 11-21:
Physical Therapy Referral for Acute Back Pain With Sciatica

Article Review 10-23
Association Between Chiropractic Spinal Manipulation and Lumbar Discectomy in Adults with Lumbar Disc Herniation and Radiculopathy