Did you know that, when chiropractic is first, opioids come last…and mostly not at all?
What if there were research, based on over 100,000 data points, that clearly indicated chiropractic is the answer to the opioid epidemic in the US? Would you, as a chiropractor or chiropractic patient or even simply as a compassionate human being, want to share that information? Would you want to be part of saving 130 lives a day?
That research does exist, and in this article, you will find the details and links you need to start having this life-saving conversation in your community.
Artificial and Innate Intelligence, a Beautiful Friendship
At the 2019 Chancellor’s Plenary session, held on the campus of Life University during its annual Fall CElebration, Dr. Gerry Clum, presented the findings from a study that Life U did with Quid, an artificial intelligence research giant. This study explored the subject of the unmet needs of the healthcare consumer relative to chronic pain. Specifically, we (Life U, Today’s Chiropractic Leadership, and Quid) looked at this question in the context of opioid use and the crises that exist around that use. Those findings were then cross-referenced with basic outcomes research associated with chiropractic care, opioid use, and others. Based on that work, Dr. Clum shared some clear conclusions that beg the questions asked above.
Below, you will find a video and transcript of Dr. Clum’s entire Plenary presentation. To whet your appetite relative to the presentation, here are the three datasets that were explored in our study.
We looked at the status of chronic pain:
- Relative to the research community in alternative care,
- In relationship to the voice of the media relative to non-pharmacological care
- Relative to the voice of the patient with regard to non-pharmacological care
Non-Pharma Care Is the Clear Answer
We explored those questions in the context of non-pharmacological care because, despite the devastating prevalence of opioid prescriptions, non-pharmacological approaches are at the center of the recommended first order guidelines for addressing pain from the Center for Disease Control and Prevention (CDC), the Food and Drug Administration, the Academy of Family Physicians, and others similar agencies across the country. The research is clear. Rather than opioids, rather than drugs, the non-pharma approach should be the leading approach.
Since that’s the case, our work with Quid allowed us to be part of the conversations people are having, all across the country in multiple arenas, about chronic pain. We were able to look at 10,000 research articles addressing chronic pain in a three-year period and analyze them for their content relative to non-pharmacological care. We found that 10% of chronic pain research articles reflected the non-pharma discussion. Then we looked at the media and asked, “What’s the media discussion about chronic pain, specifically relative to non-pharma care?” We found that 40% of the media discussion was associated with non-pharma care. Then, we looked at the discussion on the part of the patient and what was driving them. We identified in our review a series of eight needs that originated with patients, after looking over 100,000 patient blog posts, advocacy groups, feedback sites, et cetera. This massive review allowed us to get the sense of chronic pain patient using the Quid technology.
Chiropractic: The Chronic Pain Patient’s Choice
The Quid technology also enabled us to graph out what people were interested in and excited about. The good news for the chiropractic community is that chiropractic care fared very well in the sentiment discussion on the part of the consumer. It fared better than marijuana, acupuncture, and massage. Notably, it fared far better than cognitive behavioral therapy and exercise, which were two of the recommendations that had come from CDC. We were then able to take that information and get a fairly clear picture of what the consumer wants, needs, hopes for, and even dreams about relative to the management of chronic pain. Then, of course, we looked at the reality of patients’ lived experience in the chronic pain landscape. We asked, “What’s the likelihood of someone with an on-the-job or low back injury winding up getting surgery if they see a surgeon first vs. if they see a chiropractor first?” Staggeringly, the evidence shows that a patient is 28 times more likely to end up with surgery when their first contact for that type of injury is with a surgeon.
It should be clearly noted that we’re talking apples to apples cases here. We’re not talking about comparing patients who’ve had horrific injury, such as having a building collapsed with patients who are dealing with lumbosacral sprains. That is such a stark difference that it’s worth reiterating: We made truly equitable, apples to apples comparisons, and saw a factor of 28 times more surgery for patients who started under care with a surgeon versus those who started care with a chiropractor.
Chiropractic Prevents Opioid Use
Next, we began to look at the utilization of opioids and how their use is affected when chiropractic care is involved in the chronic pain environment, particularly the low back environment. The study showed dramatic reductions, potentially up to 95% less likelihood of patients using opioids when chiropractic care was involved. Again, that bears repeating: Patients with chronic pain, especially those with low back pain, are 95% less likely to take opioids if they are under chiropractic care.
In the end, there is quite a punchline to our Quid study, but we’re not going to give it away. Instead, we’d like to ask everyone to go to view the video of Dr. Clum’s Plenary presentation, which you’ll find embedded below, and a transcript of his presentation below that.
At the end of his Plenary presentation, Dr. Clum posed a game changing question and pondered whether it’s time for us, as a profession, to ask it.
Please take the time to watch this 21-minute presentation. Then, take a look at the Quid report, Hearing the Unmet Needs of Patients Suffering Chronic Pain.
More to Come…
Stay tuned, too, so that you can also download a copy of the PowerPoint from the presentation so that you’ll have the slides available as well. After that, let us hear from you, either in comments below or by emailing TCL@LIFE.edu. We want your thoughts on what we might be able to do, together across the profession, to help folks in the chronic pain environment.
Dr. Riekeman: There are a few people in the profession that you can just use their first name and everybody knows who you’re talking about. Right? Sid. BJ. Gerry. Right? So without further ado, Gerry.
Dr. Clum: This is really kind of an odd spot to be speaking to you from today. I’m talking about something that is not part of our practice. It’s something that we don’t prescribe, something we don’t do, something we don’t recommend, something we’re not in favor of, but something that we’re all greatly impacted by and we’re talking about it in relationship to the moment that we’re in as a nation and what’s happening around us about this subject that is a product of the Law of Unintended Consequences, or is just serendipity, or whatever it might be, but the opioid discussion has the roots of being one of the most important things to have ever happened to the chiropractic profession in our history.
Now before any of you take from my remarks, the idea that I am in favor of chiropractic as a sole and singular treatment of pain, whether it be back pain, or neck pain, or headache, or whatever the case might be, I don’t see it that way. I got under chiropractic care as a 12-year-old kid because I had a problem with my eyesight, and I had a miraculous recovery. From the time I was 12, I thought chiropractic care was for blindness. I didn’t think it had anything much to do with backs. And over the course of time, obviously we have encountered all sorts of problems, all sorts of circumstances, and at the root and the core of what we do and why we do it, is about that transition that Stephanie* spoke about this morning, where we moved to that wellness model. But, people have to let us into their lives at one time or another, in one way or another.
And the discussion of pain becomes a driver for most patients, unfortunately. And as a result, we need to understand the discussion, understand the language, and understand the implications of where this situation is going. Dr Riekeman has given me the privilege to work with Life University and Quid, which is an artificial intelligence (AI) corporation out of San Francisco, and it’s really one of the premier companies of its kind in the world. CNBC has identified Quid as the leading edge of artificial intelligence information acquisition and development. So it’s a very, very cutting edge opportunity. And one of the things that we have to learn to do is [find out], “How do you ask questions in this environment?” This is not glorified Google. It’s not, “What’s the average temperature in Atlanta?” That’s Google. That’s what Google’s for.
That’s good. That’s great. It [Quid] is, “What do people in Atlanta think about having 91 days of temperatures in excess of 90 degrees in 2019 in relationship to what it was like when they grew up and were kids here without air conditioning?” Huh? Well, there’s a way to get to that information. And that’s what artificial intelligence is about. And what Quid does is, Quid is real language interpretation. It’s having a thousand or 10,000 Stephanies* sit down and read those articles one by one and extract the data from it and have a machine do that, extracting it in the real language that it’s written in, and then to be able to interpret the meaning of the language as positive or negative, supportive, contradictory, hostile, et cetera, and then to draw conclusions from it. So, one of the things that [Quid] does is, it gives us a chance to look at massive amounts of information in a very short period of time.
So, we began the question of looking at the unmet needs of patients suffering from chronic pain in relationship to the opioid crisis, and how could we use AI in this environment. One article has been published in the New England Journal of Medicine looking at healthcare through the lens of artificial intelligence using Quid. So that that door has been opened. Now we’re coming in with another discussion of it from a different angle to begin the process and see what we can do, as Dr. Riekeman said, and I think I’ve said already, my thanks to Life and to Today’s Chiropractic Leadership for the opportunity to be involved with [Quid].
If you have been living under a remarkably large rock for a long time, you might’ve escaped something to do with the opioid discussion. But we’re talking about 130 deaths per day from opioid use, on a very conservative basis. That could easily be 200 and we’re talking about 40% of those deaths coming from prescribed opioids. These are not illegal. These aren’t somebody on the street corner. This isn’t something that happened over the internet. This is somebody walking into Walgreens. This is somebody that would go to CVS. And we talked about the idea that in just 20 years, this has increased 400% in the United States. It’s a hell of a problem. We’ve lost 400,000 citizens as a result of this over time. So we began the process of looking at information, using Quid, about where we are in this whole world of information concerning opioids and,…ultimately, we want to get to the question of, “What is the voice of the patient saying?” So, we started with a discussion about, “What’s the…research community saying?”
And then we began to look at, “What the media is saying?” And then we got down to, “What is the patient saying?” Let me see if we can walk through this together, if we can get some cooperation from the AV stuff here. So, our first question we began with was the voice of the researchers. You know, let’s begin with, “What’s out there? What’s published and what’s considered scientific at the moment?” And, in that process, we analyzed 10,000 articles in the period of 2013 and 2015 that dealt with chronic pain in one way or another. Now, in looking at that, we were able to extract from that, what percentage of these articles are talking about…traditional pain care of opioids and everything else, and what percentage are talking about non-pharma care. And we found out that 10% of the literature being published in that two-year period was looking at non-pharma approaches to chronic pain problems in that part of the population.
So in looking at that 10,000, that that was a good place to start. And so, with that bit of information, we then went on to the second question and we said, “Well, what’s the media saying?” And we looked at 50,000 media outlets, media news posts, and blog posts for the same questions: “What is the discussion of the chronic pain community?” This [community] is [made up of] persons that are active in that field. This is caretakers, this is people that are going online to the muscular dystrophy patient support page. And they’re there talking to each other about their experiences with muscular dystrophy or multiple sclerosis or arthritis, whatever it might be. And what are they saying? And we collect that data out of that. And in that, we found that 40% of that discussion was talking about non-pharma approaches to healthcare and non-pharma approaches to chronic pain.
So, 10% of the research is non-pharma, now 40% of the media discussion is…talking about things of our world and things of our ilk. And then, we can break it down into what that 40% represents. And what the consumer is looking for, are things associated with improving access to healthcare. [That] was the number one. And this is what Dr. Sullivan talked about. This is what Dr. Gertz** talked about. What they want to know is, “Who do I turn to? Who’s going to give me the good stuff?” I shouldn’t say it that way. “Who’s going to give me the good care that I want?” and so on. And then we go on to the idea that the second category of information that they were looking at in the non-pharma world was us, was alternative approaches to healthcare, non-traditional, non-medical approaches, and non-pharma approaches to health care.
And then you can read the list and go through there. You’ve got them in the booklets that you’ve got printed at your seats and obviously you can read them off the sides and you can see how that goes. But you can also see that how much they cluster; there isn’t a great range. It goes from 7.2 to what’s the lowest level 4.4. It’s not like it’s 40% and 1% or something like that; it’s a relatively close-knit thinking that’s looking at these things and trying to figure their way out of a significant problem. So, then the third situation is, “Well, what’s the patient saying?” And now, this time we went to 100,000 blogs and posts associated with consumers who were commenting on chronic pain problems. And this included persons in pain and caretakers. Those were the two main major categories that we were after in this environment.
And out of this, we found that there were eight areas and eight key needs that were revealed on the part of those consumers. And you can see them again on the screen… These are in order of frequency. They are not necessarily percentage ranked specifically, as the last slide was. But they want access to quality providers, for example. They want to know who to turn to and they want to have the options to develop their own client care plan, if necessary. Persons in chronic pain have already gone about the process of developing their own system. They’re out there. They are knowing that the next opioid prescription isn’t the answer, and they’re beginning to look and beginning to cobble together their own community of providers to give them the direction that they need.
Now this is perhaps the most important piece of information I can give you today in looking at this…this is called a sentiment plot. And where you want to be is in the upper left hand corner… Those are circumstances that have high utility and high value to the consumer. And if you look where we are, it happens to be at the point of that arrow. We’re very well placed. If you also look over here at the concept of multimodal care, we are within that definition and discussion on the part of the consumer. So, we see that chiropractic specifically, multimodal care more generally (which would include more of the conversation that…Christine Gertz talked about), again, figures very high. But if you look, for example, right smack in the center, that one lone dot right there in the heart of it, is marijuana.
It doesn’t necessarily work too well, but there’s a moderate level of interest in it on the part of the consumer. Okay. If we look underneath that arrow on the far left, you see things like implantables, you’ll see things like novel surgical approaches and so on. These are things that people think about and that they’re interested in, but there’s not a great deal of uptake in them. They’re the current novelty-of-the-day discussion. The long haul involvement, specifically in terms of what’s going on…[in] healthcare, we came out on top of this discussion. Now again, this is chronic pain patients. This is…where the rubber meets the road [extrapolated from] 100,000 different blogs. But it’s important for you to look down here in this other corner. And that’s cognitive behavioral therapy. If you go to the recommendations of the CDC and the FDA and what used to be the Institute of Medicine and is now the National Academy of Medicine, they all recommend non-pharma approaches to care, but CDC doesn’t say chiropractic care. CDC recommends exercise and cognitive behavioral therapy or CBT. The point to take away from this is, the last thing the consumer wants is CBT. So you’ve got government coming to the table saying, this is the good stuff you ought to get, and the patients saying, you’ve lost your mind. I don’t want any part of that crap. And that difference is very important for us to plot where we’re going to go next and how we begin to engage this discussion, in just a couple of seconds here.
Now, I’m going to jump gears completely. Quit thinking Quid…and now think, “What has given driven these people into opioid use to begin with?” Well, low back pain is the top of the list. This is a study from the state of Washington, where persons were injured at work, and it talked about what determines their care. And it comes down to who they see as a provider. If they see a surgeon, …43% of those are going to have surgery. If they see a chiropractor, 1.5% of those persons are going to have surgery within three years. That’s a factor of 28.66 times more surgery. What’s important to understand in this study, is that these were case equivalent patients, that the patients that were seeing the chiropractors and the patients that were seeing the surgeons had comparable levels of disability and problem and damage. So, it’s not as if the surgeons are seeing the fractures and the terrible stuff and you and I are seeing the cricks, back aches, and strains routine. They were the same across the board. And we wind up with a ratio of 28 times more surgery in that environment. The number one predictor of whether a person’s going to go on to long term therapy with opioids is failed back surgery.
This came out August 30th, less than six weeks ago. This is from Health and Human Services and this is the brand new federal best practices regarding pain in the United States. It’s 86 pages long. We have about three lines in the entire discussion.
And they’ve identified two gaps. The first is, there’s a lot of stuff out there that we’re not using that we should be using. That’s us [chiropractic]. And the second gap they found is, “We don’t really know what that stuff is and…we’re kind of fuzzy about it.” And what was their statement regarding chiropractic care? “Osteopathic and chiropractic treatments are commonly used in pain management.” That’s the best the federal government delivered to us in an 86-page report. Okay, I’ll take it. I can use that in court someplace. I can use that in a trial sometime. The bottom line is we’ll take that one line and we’ll run with it when we can, but what could we build on it with? Remember opioids is the discussion. This paper came out September 2nd, a little bit more than a month ago.
This is good stuff. This is, number one, written by almost all medics. Dave Elton, one of the authors at the bottom is a chiropractor. The rest of them are medics. And what we’re looking at here is the potential – based upon initial healthcare provider with new onset, low back pain – to get into opioid use. I’ll cut to the chase and tell you that the reality is that they found a negative relationship between chiropractic care and opioid use. In that discussion, that’s a good thing. The more there are of us, the less there is of opioids. And so, they identified that low back pain was the most common condition for which opioids are…most frequently prescribed, and that half of the opioid users got there by way of back pain. And it [back pain] is one of the most common things that comes into the physician’s office in the United States. So, what was the net effect? Patients who received initial care from a chiropractor decreased the odds of short and long term opioid use compared with those that saw primary care providers. Well, okay. But, was it a lot, was it a little, where was it? Well, there was a 90% reduction in opioid use – a 90% reduction with chiropractic care in this environment.
This was last week, showed up in Pain Medicine, and was related to one of the studies that Christine Gertz was talking about. And this is specifically relative to chiropractic care and opioid receipt associated again with new events of low back pain. And the bottom line here was that overall, chiropractic users had 64% lower odds of receiving an opioid prescription than non-users. So, where do we take these two information sets? We’ve got all sorts of movement by every guideline that’s out there saying non-pharma approaches need to be the order of the day. Period. Number two, we’ve got the consumer moving in our direction and in the non-pharma world, we’ve identified that chiropractic care has one of the highest positive sentiments of any intervention that’s out there. So we’re very, very well positioned to that. Now we look at, specifically, discussions in relationship to chiropractic care, opioid use, and do we affect that in a positive way?
Absolutely. We truncate the use of it. If we’ve got a 90% reduction, we are stopping the use. They’re not getting to the first script. Period. Which is a huge incentive in this discussion. So, this all brings us back to one question that perhaps we might be able to ask, with a very straight face and legitimately in this discussion, is that, “Is it time for us to put forward a question to the rest of healthcare, is that if under non-pharmacological care there’s a potential for a 28 times reduction in the amount of spine surgery, and if there’s between 64 and 90% reduction in opioid use potential, are we at a point in time where the failure of a primary care provider to refer a patient for non-pharmacological constitutes malpractice?”
Don’t say, “Clum said it’s malpractice.” Clum said, “It’s time to ask the question.” We need better questions. We need more of them. And I thank Life University and Dr. Riekeman for the chance to participate with Quid and with all of you in that endeavor. Thank you.
*referring to Dr. Stephanie Sullivan, director of the Life University Sid E. Williams Center for Chiropractic Research.
**referring to Dr. Christine Goertz, vice chancellor for research and health policy at Palmer College of Chiropractic