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KristynZrenda,DO ColonyFugate,DO AmandaFoster,DO
ANSWER
SUMMARY OF EVIDENCE
CRITERIA
ACKNOWLEDGEMENTS
§ InAmerica,prescriptionopioiddeathssecondarytooverdosehavemorethanquadrupledbetween1999and2015(2,9)
§ Misusedinpersons12yearsoroldermorethananyotherdrugofabuseexceptmarijuanain2012(4)
§ Sixoutoftendrugoverdosedeathsinvolveopioids(2)§ Opioidoverdosedeaths:91Americansperday(2)§ Overprescribingandprescribingpriortofirst-lineagentsin
scenariosincludingheadaches(3)§ 46%adolescentswithheadachereceiveopioidswith29%
receiving3ormoreprescriptions(3)§ Increaseinaccidentalandintentionalpediatricexposurewith
21,928pediatricemergencyvisitsbetween2006-2012duetoopioidpoisonings;thisincidencecontinuestoincrease(10)
§ 62%ofthosepoisoningswereunintentional,11childrendied,and39requiredmechanicalventilation(10)
§ Adolescentsareahighriskpopulation:oneinfourhighschoolseniorshavebeenexposedandoneinfivemisuseopioids(4)
§ 58%ofadolescentswhomisuseprogresstoaddiction,42%toabuse,andofthosewhoabuse16%progresstoheroinabuse(4)
§ Adolescentsdiscordantlyreportopioiduse(5)
§ Firstlinemanagementforchroniclowbackpainconsistsofacetaminophenandnon-steroidalanti-inflammatorydrugswithsecondarymedicationsincludingtramadolandopioids(11)
§ Adjuncttherapiesincludespinalmanipulation(OMM/OMTorchiropractic),acupuncture,exercisetherapy,massage,behavioraltherapy,andmultidisciplinaryrehabilitation(11)
§ Fewhighqualitytrialsspecificallyregardingopioidsforchronicpainhavediscussedefficacyandpotentialrisks(tolerance,hyperalgesia,allodynia)whichcanleadtohigherdosesandmorefrequentuseleadingtomisuseandabuse(11)
§ Spinalmanipulationhasbeenshowntoprovidereliefofbackpain,improvepsychologicalwell-being,andincreasefunctioning(11)
§ In1999,Anderssonetal.comparedOMM/OMTwithstandardtherapies(analgesics,anti-inflammatorymedications,activephysicaltherapy,ortherapiessuchasultrasonography)inarandomized,controlledstudyinpatientswithbackpainlasting3weeksto6months(6)
§ Usingmultipleevaluations,thestudyshowedimprovementinpainwithbothOMM/OMTandstandardtherapieswithoutstatisticalsignificance(6)
§ Secondaryoutcomes(lessmedicationuse)weresignificantlylessintheOMM/OMTgroup(p<0.001)(6)
§ OSTEOPATHICTrialevaluated455participants’shorttermreliefoflowbackpainwithOMM/OMTversusultrasoundtherapyusingIMMPACTrecommendations(8,12)
§ OMM/OMTversusshamOMM/OMTshowedmoderatetosubstantialimprovementinlowbackpain(P<0.001);nostatisticalsignificancebetweenultrasoundtherapyandshamultrasoundtherapy(8)
§ OMM/OMTwasfoundtobeefficaciousinreductionofpainperceptionwhileultrasoundtherapywasnotandOMM/OMTresultedinlesspainmedicationuse(p<0.048)(8)
§ AdditionalLicciardoneetal.studylookedatoutcomesofOMM/OMTonchroniclowbackpainaccordingtobaselinepainseverityonreviewoftheOSTEOPATHICTrial(7)
§ Greaterthan50%reductioninpainperceptionwasnotedin51%oflowbaselinepainparticipantsand41%highbaselinepainparticipantswithOMM/OMT(7)
§ UseofprescriptionpainmedicationswasalsosignificantlyreducedwithOMM/OMTcomparedtoothermodalities(7)
LiteraturesuggestionsthatOMM/OMTisapossibleefficaciousadjunctivetherapyinthemanagementofchronicpain.EvidencealsosuggeststhatuseofOMM/OMTcandecreasetheuseofopioidanalgesicsinthemanagementofchronicpain;whichtherebymaydecreasedetrimentaloutcomes(misuse,abuse,addiction,deathsfromopioidoverdose,intentionaloverdosesinadolescents,andunintentionaloverdosesinchildren)ofournation’sopioidepidemic.
SearchTerms:osteopathic,manipulation,chronicpain,opioidInclusionCriteria:Retrospective,randomized,controlled,cross-sectional,andblindedcohortstudiespublishedafter1998regardingthetopicaswellascurrentguidelinesinchronicpainmanagementandopioidepidemicdata.ExclusionCriteria:Non-Englishlanguagearticles
ResearchthusfarhasshownconcerningstatisticsregardingtheopioidepidemicintheUnitedStateswithincreasedratesofmisuse,abuse,addition,opioidoverdosedeaths,adolescentintentionaloverdoses,andpediatricunintentionaloverdoses.Therearemultipleadjunctivetherapiesavailableinthemanagementofchronicpain;whichisamajorcauseforopioiduseandprescribing.OneadjuncttherapywithsomeevidenceofefficacyisOMM/OMT.WhilestudieshaveshownbenefitsinthemanagementofchronicpainwithOMM/OMT,furtherresearchisneeded,specificallyhigh-qualityresearch,astotheefficacyandlongevityofmanagementwithOMM/OMTforchronicpainaswellasitsroleindecreasinguse,misuse,andabuseofopioidanalgesics.
SUMMARY OF ISSUES
CONCLUSION
Misusedefined• “useofapsychotropicmedicationwithoutaprescription”or• “ingreateramounts,moreoften,orlongerthanprescribed”(9)
CLINICAL QUESTION Inaneraofopioidmisuseandabuse,isosteopathicmanipulativemedicine(OMM,alsoknownasosteopathicmanipulativetreatmentortherapy,OMT)apossiblealternativeadjunctivetherapyforstandardtherapiesinplaceofopioidmedicationsinthemanagementofchronicpaintoreducethedetrimentaloutcomesinbothadultsandchildren?
BlevelofevidenceDefined:Consistentlevel2or3studiesorextrapolationsfromlevel1studies(1)
LEVEL OF EVIDENCE
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2. Center forDiseaseControlandPrevention (Ed.). (2017,August30).UnderstandingtheEpidemic.RetrievedDecember28,2017, fromhttps://www.cdc.gov/drugoverdose/epidemic/index.html
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2015;25(2):105-112.doi:10.1080/1067828x.2014.918005.5. PalamarJ,etal.DiscordantreportingofnonmedicalopioiduseinanationallyrepresentativesampleofUShighschoolseniors.AmJDrugAlcoholAbuse.2016;42(5):530-538.6. Andersson,G.B.,MD,PhDetal(1999).AComparisonofOsteopathicSpinalManipulationwithStandardCareforPatientswithLowBackPain.TheNewEnglandJournalofMedicine,
341(19),1426-1431.doi:10.1056/NEJM199911043411903
7. LicciardoneJ,KearnsC,MinottiD.Outcomesofosteopathicmanualtreatmentforchroniclowbackpainaccordingtobaselinepainseverity:ResultsfromtheOSTEOPATHICTrial.ManTher.2013;18(6):533-540.doi:10.1016/j.math.2013.05.006.
8. Licciardone J,Minotti D, et al.OsteopathicManual Treatment andUltrasound Therapy for Chronic LowBack Pain: A Randomized Controlled Trial.TheAnnals of FamilyMedicine.2013;11(2):122-129.doi:10.1370/afm.1468.
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10.1080/00952990.2016.1194851.11. Last,A.R.,MD,PhD,MPH,etal(2009).ChronicLowBackPain:EvaluationandManagement.AmericanFamilyPhysician,79(12),10671074.Retrievedfromhttps://www.aafp.org/afp/
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