The association between chiropractic integration in an Ontario community health centre and continued prescription opioid use for chronic non-cancer spinal pain: a sequential explanatory mixed methods study.

BACKGROUND: Emerging evidence suggests that access to chiropractic care may reduce the likelihood of initiating an opioid prescription for spinal pain; however, the impact of chiropractic care for patients already prescribed opioids is uncertain. We undertook a sequential explanatory mixed methods study to evaluate the association between initiating chiropractic care and continued opioid use among adult patients attending an Ontario community health centre (CHC) and receiving opioid therapy for chronic non-cancer spinal pain. METHODS: We conducted a retrospective cohort study of 210 patient records between January 1, 2014 and December 31, 2020. We used generalized estimating equations, adjusted for patient demographics, co-morbidities, visit frequency, and calendar year, to evaluate the association between receipt versus non-receipt of chiropractic services and continued opioid use (e.g., unique opioid fills, number of refills, and dosages) up to one year following the index chiropractic visit. We also completed follow-up interviews with 14 patients and nine general practitioners from the CHC and integrated these data with our quantitative findings. RESULTS: Over 12-month follow-up, there were lower rates of opioid fills (incidence rate ratio [IRR] = 0.66; 95% confidence interval [CI], 0.52-0.83) and refills (IRR = 0.27; 95% CI, 0.17-0.42) among chiropractic recipients (n = 49) versus non-recipients (n = 161). Although patients who did and did not receive chiropractic care began the study with the same dose of opioids, recipients were less likely to be prescribed higher-dose opioids (i.e., ≥ 50 mg morphine equivalents daily) compared to non-recipients at three months (odds ratio [OR] = 0.14; 95% CI, 0.04-0.47), six months (OR = 0.14; 95% CI, 0.05-0.40), nine months (OR = 0.19; 95% CI, 0.07-0.57), and 12 months (OR = 0.22; 95% CI, 0.08-0.62). Interviews suggested that patient self-efficacy, limited effectiveness of opioids for chronic pain, stigma regarding use of opioids, and access to chiropractic treatment were important influencing factors. CONCLUSION: We found that continued prescription opioid use among patients with chronic non-cancer spinal pain who received chiropractic care was lower than in patients who did not receive chiropractic care. Four themes emerged in our qualitative interviews to help provide a richer understanding of this association. Randomized controlled trials are needed to establish the effect of chiropractic care on opioid use for chronic spinal pain.

Association of Chiropractic Care With Receiving an Opioid Prescription for Noncancer Spinal Pain Within a Canadian Community Health Center: A Mixed Methods Analysis.

OBJECTIVE: The purpose of this study was to examine the association between receipt of chiropractic services and initiating a prescription for opioids among adult patients with noncancer spinal pain in a Canadian community health center. METHODS: In this sequential explanatory mixed methods analysis, we conducted a retrospective study of 945 patient records (January 2014 to December 2020) and completed interviews with 14 patients and 9 general practitioners. We used Cox proportional hazards regression analyses, adjusted for patient demographics, comorbidities, visit frequency, and calendar year to evaluate the association between receipt of chiropractic care and time to first opioid prescription up to 1 year after presentation. Qualitative data were analyzed thematically and integrated with our quantitative findings. RESULTS: There were 24% of patients (227 of 945) with noncancer spinal pain who received a prescription for opioids. The risk of initiating a prescription for opioids at 1 year after presentation was 52% lower in chiropractic recipients vs nonrecipients (hazard ratio [HR], 0.48; 99% confidence interval [CI], 0.29-0.77) and 71% lower in patients who received chiropractic services within 30 days of their index visit (HR, 0.29; 99% CI, 0.13-0.68). Patients whose index visit date was in a more recent calendar year were also less likely to receive opioids (HR, 0.86; 99% CI, 0.76-0.97). Interviews suggested that self-efficacy, access to chiropractic services, opioid stigma, and treatment impact were influencing factors. CONCLUSION: Patients with noncancer spinal pain who received chiropractic care were less likely to obtain a prescription for opioids than patients who did not receive chiropractic care.

Chiropractic integration within a community health centre: a cost description and partial analysis of cost-utility from the perspective of the institution.

OBJECTIVE: To evaluate costs and consequences of a new back pain service provided by chiropractors integrated into a Community Health Centre in Cambridge, Ontario. The study sample included 95 consecutive patients presenting between January 2014 to January 2016 with a mixture of sub-acute and chronic back pain. METHODS: A secondary cost-utility analysis was performed and conducted from the perspective of the healthcare institution. Cost-utility was calculated as cost per quality-adjusted life year (QALY) gained over a time horizon of 90 days. RESULTS: According to the EuroQol 5 Domain questionnaire, nearly 70% of patients improved. The mean number of treatment sessions was 8.4, and an average of 0.21 QALYs were gained at an average cost per QALY of $1,042. Seventy-seven percent of patients did not visit their primary care provider over the 90-day period, representing potential cost savings to the institution of between $2,022.23 and $6,135.82. CONCLUSION: Adding chiropractic care to usual medical care was associated with improved outcomes at a reasonable cost in a sample of complex patients with sub-acute and chronic back pain. Future comparative cost-effectiveness studies are needed.

OBJECTIF: Évaluer les coûts et les conséquences d'un nouveau service pour soulager les maux de dos offert par des chiropraticiens intégrés à un centre de santé communautaire à Cambridge, en Ontario. L'échantillon de l'étude comprenait 95 patients qui se sont présentés consécutivement entre janvier 2014 et janvier 2016 et qui étaient atteints de diverses douleurs dorsales subaiguës et chroniques. MÉTHODES: Une analyse coût-utilité secondaire a été effectuée du point de vue de l'établissement de santé. Le coût-utilité a été calculé en tant que coût par année de vie ajustée en fonction de la qualité (AVAQ) obtenu sur une période de 90 jours. RÉSULTATS: Selon les résultats du questionnaire EuroQol 5 Domain, près de 70 % des patients ont observé une amélioration de leurs symptômes. Le nombre moyen de séances de traitement était de 8,4 et une moyenne de 0,21 AVAQ a été obtenue à un coût moyen par AVAQ de 1 042 $. Soixante-dix-sept pour cent des patients n'ont pas consulté leur fournisseur de soins primaires au cours de la période de 90 jours, ce qui représente des économies potentielles de l'ordre de 2 022,23 $ à 6 135,82 $ pour l'établissement. CONCLUSION: L'ajout de soins chiropratiques aux soins médicaux habituels a entraîné une amélioration des résultats à un coût raisonnable pour un échantillon de patients ayant des besoins complexes et présentant des douleurs dorsales subaiguës et chroniques. De futures études comparatives coût-efficacité sont nécessaires.

Management of Back Pain-related Disorders in a Community With Limited Access to Health Care Services: A Description of Integration of Chiropractors as Service Providers.

OBJECTIVE: The purpose of this study was to evaluate a chiropractic service for back pain patients integrated within a publicly funded, multidisciplinary, primary care community health center in Cambridge, Ontario, Canada. METHODS: Patients consulting for back pain of any duration were referred by their medical doctor or nurse practitioner for chiropractic treatment at the community health center. Patients completed questionnaires at baseline and at discharge from the service. Data were collected prospectively on consecutive patients between January 2014 and January 2016. RESULTS: Questionnaire data were obtained from 93 patients. The mean age of the sample was 49.0 ± 16.27 years, and 66% were unemployed. More than three-quarters (77%) had had their back pain for more than a month, and 68% described it as constant. According to the Bournemouth Questionnaire, Bothersomeness, and global improvement scales, a majority (63%, 74%, and 93%, respectively) reported improvement at discharge, and most (82%) reported a significant reduction in pain medication. More than three-quarters (77%) did not visit their primary care provider while under chiropractic care, and almost all (93%) were satisfied with the service. According to the EuroQol 5 Domain questionnaire, more than one-third of patients (39%) also reported improvement in their general health state at discharge. CONCLUSION: Implementation of an integrated chiropractic service was associated with high levels of improvement and patient satisfaction in a sample of patients of low socioeconomic status with subacute and chronic back pain.