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Dynamic Chiropractic – October 15, 2014, Vol. 32, Issue 20

Uncle Sam Needs You

Part 1: Exposing the military "pill mill" and advocating a better way to manage pain.

By J.C. Smith, MA, DC

Scrutiny into the Department of Veterans Affairs (DVA) continues to grow after efforts to reform the DVA by the former Secretary of Veterans Affairs, Eric Shinseki, were deemed "a stunning period of dysfunction" by Senate Minority Leader Mitch McConnell (R-Ky.).

Controversial issues range from cooked books to protracted delays causing deaths at Veterans Affairs hospitals; insufficient patient care personnel; unwarranted staff bonuses; and punishment of whistleblowers.

According to these reports, legislators now investigating this complex DVA dysfunction have suffered from sticker shock at the cost of $35 billion through 2016 and thereafter $50 billion a year to care for the 6.5 million vets seeking VA treatment every year.1 More alarming corruption was found within the veterans health care system, including overpaying some 13,000 clerks, administrators and other support staff.2

Pill Mill Military

Adding to the many administrative issues and exploding costs in the DVA, reports have recently exploded in the media about the pandemic of chronic pain and the addiction to prescription painkillers like oxycontin, hydrocodone and Percocet indiscriminately handed out like Halloween candy to active-duty military and veterans alike.

"They'd just shove you a bag of pills," said one veteran addicted to painkillers. "No matter what you needed, there was a pill. Everything under the sun, from Adderall to Percocet to hydrocodone, oxycodone, you name it."3

uncle sam - Copyright – Stock Photo / Register Mark This shocking news recently surfaced with a two-segment exposé on NPR's "All Things Considered" about the growing narcotic painkiller addiction among active military and veterans: "Veterans Kick the Prescription Pill Habit, Against Doctors' Orders," and "A Growing Number of Veterans Struggle to Quit Powerful Painkillers." These radio broadcasts revealed that this year, the VA will treat about 650,000 veterans with opiates – over the growing complaints of patients. One in three veterans polled say they are on 10 or more different medications.4

Abuse of prescription drugs is also high among active-duty service members, who are prescribed narcotic painkillers three times more often than civilians, on average.5

Dr. Richard Friedman, director of the Psychopharmacology Clinic at Weill Cornell Medical College, spoke of the "pill mill" mentality in the military: "It's like giving a football player painkillers so he can finish the game. It gets him back on the field, but might hurt him worse in the long term."6

The tsunami of painkillers is also a factor in the high rate of veteran suicide, according to Dr. Gavin West, who heads the Opioid Safety Initiative at the VA. "It's a national problem," he said, adding that the VA is trying to change its approach and stop offering opiates as a first option for pain.7

"It's always easier to just prescribe a pill. At the VA, we've really tried to work with other resources. These include acupuncture. We have aqua therapy – you know, pool therapy, and physical therapy. There really is a large arsenal for treating patients' pain."

Notably missing from this "large arsenal" is any mention of chiropractic care, which already has been shown to be more beneficial and, most of all, drug-free. Unquestionably, the best complementary and alternative medical (CAM) treatments for spine-related disorders are Chiropractic, Acupuncture and Massage therapy.

In conjunction with opioid painkillers, pain management clinicians also use controversial epidural corticosteroids injections (ESIs) that have been shown to be no better than placebo8 and have never been approved by the FDA for back pain; as noted in a recent FDA publication, "Epidural Corticosteroid Injection: Drug Safety Communication: Risk of Rare But Serious Neurologic Problems."

In another recent commentary in JAMA Internal Medicine, "Pain and Opioids in the Military: We Must Do Better," Dr. Wayne Jonas, an expert on chronic pain, and Dr. Eric Schoomaker, a former surgeon general of the Army, said that "without improvements in pain management, many service members are at risk of increasing disability throughout their lives. The loss of human potential is inestimable ... we must transform ourselves in the way we manage pain. We can and must do better."9

D.J. Aldington, advisor to the U.K. surgeon general at Churchill Hospital in Oxford, England, wrote in an invited commentary, "Back Pain: The Silent Military Threat: Comment on 'Back Pain During War,'" of the importance to study chronic pain and use of opioids that carry the risk of functional impairment of America's fighting force:10

"The importance of the medically 'mundane' condition of low back pain cannot be overstated," he said, acknowledging that the condition is often overshadowed by the more traumatic injuries of war.

"In many ways, this parallels the experience in civilian life where the organization of services and treatments for low back pain are particularly chaotic despite the huge impact it has on society as a whole."

Other prominent medical ethicists are now speaking out on the chaotic "pill mill" approach to chronic pain management. Thomas Frieden, MD, director of the CDC, minced no words in a news release when he said, "physicians have supplanted street corner drug pushers as the most important suppliers of illicit narcotics."11

Mark Schoene, associate editor of The Back Letter, a leading international spine research journal, deems the rash of drugs, shots and spine surgery the "poster child of inefficient spine care." He also states: "[that] such an important area of medicine has fallen to this level of dysfunction should be a national scandal."12 It's not only a nationwide public scandal, but now a worldwide military scandal, too.

Back Pain No. 1 Disability for Active Military Personnel

The DoD readily admits that 20 percent of disabled vets and 30 percent of hospitalizations stem from low back pain, which has become the largest disabling condition among active forces. According to research done in 2000 by Johns Hopkins School of Public Health, "Unintentional and Musculoskeletal Injuries Greatest Threat to Military Personnel," "in all three branches of the service, injuries and musculoskeletal conditions resulted in more soldiers missing time from work than any other health condition."13

A Johns Hopkins study 10 years later found that the top reasons for medical evacuation from Iraq and Afghanistan are musculoskeletal disorders, not combat injuries. In the study, "Back Pain Permanently Sidelines Soldiers at War: Few Rejoin Units in Iraq or Afghanistan Regardless of Treatment," researchers examined the records of more than 34,000 military personnel evacuated from Iraq and Afghanistan between January 2004 and December 2007. They found that 24 percent had musculoskeletal disorders, compared to only 14 percent who had suffered combat injuries.

Colonel Steven P. Cohen, MD, found only 13 percent of service members who left their units with back pain as their primary diagnosis eventually returned to duty in the field. He admitted, "If you have only a 13 percent success rate, this is a failure. There's a systemic problem ... Back pain has notoriously low success rates for treatment."

Dr. Cohen should have been more specific by stating "notoriously low success rates for medical treatment" – the typical arsenal of opioid painkillers, epidural steroid injections, physiotherapeutics and spine fusions.

Dr. Cohen suggests the biggest predictors of a poor outcome are "psychosocial factors," which certainly play a minor role. However, a compelling case can be made that a significant predictor for poor outcomes is the shortage of doctors of chiropractic to treat soldiers who routinely tote 80-pound backpacks on field duty.

Chiropractic: Treatment of Choice

The benefit of chiropractic care is certainly not a new revelation. Twenty years ago, the Agency for Health Care Policy & Research investigated the epidemic of back pain and rated spinal manipulation at the top of its treatment algorithm as a "proven treatment" for acute low back pain in adults.14

An editorial in the Annals of Internal Medicine published jointly by the American College of Physicians and the American Society of Internal Medicine (1998) also noted that "spinal manipulation is the treatment of choice" and mentioned, "Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement."15

The paradigm shift in spine care now emphasizes joint dysfunction, not "bad discs," as the primary cause of low back and neck pain. Although back pain can have different causes helped by various spine professionals, such as the rare case of disc derangement, radiculopathy and muscle trigger points, the single-largest source of pain is due to joint dysfunction.

Two recent studies by Murphy and Hurwitz found joint dysfunction was the cause of neck pain in 69 percent of cases and the cause of low back pain (lumbar and sacroiliac) in 50 percent of patients.16-17 Considering there are more than 300 joints in the entire spinal column,18 it should not come as a surprise that spinal manipulative therapy (SMT) is considered the leading treatment in the majority of cases.

For example, a 2012 study from the Washington state worker's compensation system compared patients with low back pain whose primary spine provider was a chiropractor versus a medical doctor. Type of provider seen first was associated with drastically different rates for surgery; 42.7 percent of workers who first saw an MD had surgery within two years compared to only 1.5 percent of those who saw a chiropractor first.19

"The Greatest Opportunity for Improvement"

Acting Secretary of Veterans Affairs Sloan Gibson recently told the Senate Veterans Affairs Committee it will take two years, 1,500 more doctors and more than $17 billion in taxpayer money to fix the problems plaguing the VA. "We must, all of us, seize this opportunity. We can turn these challenges into the greatest opportunity for improvement in the history of this department."20

With these hopeful declarations in mind, my suggestion to Sec. Gibson is to hire more doctors of chiropractic as primary spine providers to manage the pandemic of back pain cases without drugs, shots or surgery. Simply adding more MDs and DOs with the same "pill mill" approach is Einstein's definition of insanity: "doing the same thing over and over again and expecting different results."

Editor's Note: Part 2 of this article is scheduled to appear in the Nov. 1 issue.

References

  1. Lawder D. "Lawmakers Slam Veterans Health Bill Cost Estimate:" Reuters, June 24, 2014.
  2. Wood D. "Scandal-Plagued VA Is Overpaying Workers by Millions of Dollars, Internal Audits Find." Huffington Post, July 10, 2014.
  3. Lawrence Q. "A Growing Number of Veterans Struggle to Quit Powerful Painkillers." "All Things Considered," NPR, July 10, 2014.
  4. Lawrence Q. "Veterans Kick the Prescription Pill Habit, Against Doctors' Orders." "All Things Considered," NPR, July 11, 2014.
  5. Ibid.
  6. Ibid.
  7. Ibid.
  8. Bicket MC, et al, Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the "control' injections in randomized control trials. Anesthesiology, 2013;119:907-31.
  9. Jonas WB, Schoomaker EB. "Invited Commentary: Pain and Opioids in the Military - We Must Do Better."Arch Intern Med, June 30, 2014.
  10. Aldington DJ. "Back Pain: The Silent Military Threat - Comment on 'Back Pain During War.'" Arch Intern Med, 2009;169(20):1923-1924.
  11. Centers for Disease Control and Prevention Press Release: "CDC Vital Signs: Overdose of Prescription Opioid Pain Relievers—United States, 1999-2008." Nov. 1, 2011.
  12. "US Spine Care System in a State of Continuing Decline? The BACKLetter, 2012;28(10):1.
  13. "Unintentional and Musculoskeletal Injuries: Greatest Health Threat to Military Personnel." Johns Hopkins School of Public Health, March 14, 2000.
  14. Bigos, et al. US Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guideline, Number 14: Acute Low Back Problems in Adults. AHCPR Publication No. 95-0642, December 1994.
  15. Micozz MS. "Complementary Care: When Is It Appropriate? Who Will Provide It?" Annals Intern Med, July 1998;129(1):65-66.
  16. Murphy DR, Hurwitz EL. Application of a diagnosis-based clinical decision guide in patients with neck pain. Chiro & Manual Ther, 2011;19:19.
  17. Murphy DR, Hurwitz EL. Application of a diagnosis-based clinical decision guide in patients with low back pain. Chiro & Manual Ther, 2011;19:26.
  18. G. Cramer, Dean of Research, National University of Health Sciences, via personal communication with J.C. Smith, April 29, 2009.
  19. Keeney BJ, Fulton-Kehoe D, Turner JA, et al. Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington state. Spine, Dec. 2, 2012.
  20. Klimas J. "VA Chief: Fixes Would Take Two Years and $17 billion." The Washington Times, July 16, 2014.

Dr. J.C. Smith, 1978 graduate of Life Chiropractic College, is the author of The Medical War Against Chiropractors: The Untold Story From Persecution to Vindication. Contact Dr. Smith via his website, www.chiropractorsforfairjournalism.com.

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