Chiropractic is guided by diverse philosophies and models of care. As we enter 2017, the profession is considering its identity as one that could help bring a solution to the opioid crisis and as one which could reduce health care costs through the rights to prescribe analgesics. What are the implications of medication prescription rights for chiropractors and the profession’s potential role in reducing Canada’s struggle with opioid addiction?
Drs. Mark Erwin (Class of ’84) and Stephen Burnie (Class of ’05) have co-authored a journal article with Dr. Peter Emary, et al., examining the implications of a potential change of scope within chiropractic to include limited medication prescription rights, presently incorporated into chiropractic scope of practice in some jurisdictions worldwide, such as USA, Denmark and Australia.
In Burnie’s words, “This article speaks to an issue that is somewhat controversial in our profession but very topical, and an area where scope of practice changes may be coming. We feel it is imperative to start discussing the implications of prescribing rights so that our profession can work through the inherent issues it may come with.”
The paper, entitled “A commentary on the implications of medication prescription rights for the chiropractic profession,” was published in the Chiropractic and Manual Therapies journal and can be found online on its site at www.chiromt.biomedcentral.com/articles/10.1186/s12998-016-0114-y .
“Limited prescription rights would be of great convenience to a patient who would benefit from added relief between treatments or supplementary pain relief, particularly in the acute phase,” continues Dr. Burnie. “The practice would potentially save the patient time and reduce costs to the medical system by ensuring they don’t have to see a general practitioner for the same condition they are being treated for with chiropractic. Chiropractors are also in an ideal position to know when not to prescribe and to understand when manual treatment, exercise and other interventions would be more beneficial and less harmful. As MSK specialists, no one is better positioned to weigh the pros and cons of prescription for MSK issues.”
Early in his career, CMCC President Dr. David Wickes was (title) in (?), where chiropractic scope of practice included the ability to order tests such as … and where training included a foundation in non-pharmaceutical natural medicine. Through his administrative career, he has studied a variety of models of care and studied the effects of differing scope of practice.
Drawing on this history, he weighs in on the present question of chiropractic scope of practice in Canada, and considers the question of prescription rights:
At one side of the debate is the growing interest by many chiropractors in having access to least a limited prescription drug armamentarium as part of the management of musculoskeletal disorders. Perhaps even a further outlier would be the push by some US-based DCs to have access to many prescription drugs used to treat those non-MSK disorders traditionally managed by medical primary care physicians.
At the other end of the debate spectrum is the time-honoured philosophical stance that chiropractic was founded as a drugless profession and must remain so. However, it’s far more complicated that just these opposing views. Competition amongst various health care providers whose scopes of practice seem to be growing whilst chiropractic’s remains unchanged in many jurisdictions has led to economic concerns.
Patient need and practitioner philosophy
The positioning of chiropractic as a valuable component of a national strategy to address the opioid addiction crisis is a balancing act between the argument that being a drugless practitioner reduces the likelihood that a patient will become hooked on analgesics, and the realization that some patients with acute and chronic pain syndromes cannot be adequately managed by traditional chiropractic methods alone.
I spent decades in the US observing the debates and heated arguments about prescription drug rights for DCs and know that there are few issues more capable of enraging the traditional, vitalistic segment of our profession. Our profession struggles with its identity, leading to confusion of the general public as well as legislators and policy makers.
An inconsistent approach
Even in those parts of the world in which DCs have some prescription drug privileges, there is no consistent approach. In New Mexico, the permitted formulary includes administration of bioidentical hormones and injections of homeopathic agents, whereas in Switzerland the formulary is much more consistent with a MSK- focused practice.
Finding our footing
I’ve been asked what CMCC would do if, for example, Alberta enacted legislation to permit limited prescription drug use by DCs in that province. My response is that CMCC strives to prepare its graduates for successful practice in all of the provinces, so our curriculum would evolve to include the necessary training in science-based practices allowed by the various provinces and the necessary elements to ensure patient safety.
I encourage the thoughtful, deliberate debate of the prescription drug issue and of the expansion of access to advanced imaging procedures and laboratory diagnostic tests. A profession that refuses to consider change and that fails to acknowledge advancements made in the scientific understanding of the body is likely to become marginalized.
While chiropractors and chiropractic educators consider the implications of prescription rights, the Canadian Chiropractic Association (CCA) has recently signed a joint statement of action with the federal and provincial governments to address the opioid crisis (in Canada) because of the recognition of back pain as a key driver for current opioid prescribing.
Dr. Brian Budgell, Director of CMCC Life Sciences labs agrees that “while many patients turn to analgesics as a first approach to pain, opioid use is likely to be a late response to severe recurrent or chronic spinal pain. Hence, treatment options like chiropractic, which prevent chronicity or mitigate pain and disability, may well reduce the number of patients who turn to opioids.”
The CCA has been advocating on behalf of Canadian chiropractors and their patients for greater access to conservative care options as first-line treatment of MSK conditions. “By providing prompt access to clinical alternatives, like chiropractic care, evidence suggests that we can reduce reliance on opioids to treat acute and chronic MSK-related pain,” says CCA Chair Dr. David Peeace.
(Indeed, according to Budgell, a number of well-designed studies have shown that spinal manipulation is a competitive treatment option for chronic neck (1) and back pain (2), and can also be cost effective (3).)
CCA Chief Executive Officer Alison Dantas adds that the organization is ”looking to build an understanding of how to better integrate care that is already available in communities across Canada,” and that “Integrating chiropractors into interprofessional care teams has been shown to reduce the use of pharmacotherapies and improve overall health outcomes. This effort is even more important now because the new draft Canadian prescribing guidelines strongly discourage first use of opioids.”
For more information on the Joint statement of action, please visit:www.canada.ca/en/health-canada/services/substance-abuse/opioid-conference/joint-statement-action-address-opioid-crisis.html
This article is taken from the spring 2017 issue of Primary Contact.
1) Saayman, Hays and Abrahamse J Manipulative Physiol Ther. 2011 Mar-Apr;34(3):153-163)
2) Enix et al. op Integr Health Care. 2015 ;6(1):Online access only 17 p; Giles and Muller. J Manipulative Physiol Ther. 2005 Jan;28(1):3-11)
3) Vavrek, Sharma and Hass. J Manipulative Physiol Ther. 2014 Jun;37(5):300-311)