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

1.  Welborn,MD,MPH.,McCarthy,MLIS.Clin-IQPreparationToolkit.Osctr.ouhsc.edu.2014.Availableat:http://osctr.ouhsc.edu/sites/default/files/Clin-IQ%20Toolkit%20%207-21-14.pdf.AccessedDecember28,2017.

2.  Center forDiseaseControlandPrevention (Ed.). (2017,August30).UnderstandingtheEpidemic.RetrievedDecember28,2017, fromhttps://www.cdc.gov/drugoverdose/epidemic/index.html

3.  DeVriesA,etal.OpioidUseAmongAdolescentPatientsTreatedforHeadache.JournalofAdolescentHealth.2014;55(1):128-133.doi:10.1016/j.jadohealth.2013.12.014.4.  VosburgS,etal.PrescriptionOpioidAbuse,PrescriptionOpioidAddiction,andHeroinAbuseAmongAdolescentsinaRecoveryHighSchool:APilotStudy.JChildAdolescSubstAbuse.

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.

9.  HanB,etal.PrescriptionOpioidUse,Misuse,andUseDisordersinU.S.Adults:2015NationalSurveyonDrugUseandHealth.AnnInternMed.2017;167(5):293.doi:10.7326/m17-0865.10.  Tadros A, et al. Emergency department visits by pediatric patients for poisoning by prescription opioids. Am J Drug Alcohol Abuse. 2016;42(5):550-555. doi:

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/

2009/0615/p1067.html12. McGrathP,etal.CoreOutcomeDomainsandMeasuresforPediatricAcuteandChronic/RecurrentPainClinicalTrials:PedIMMPACTRecommendations.TheJournalofPain.2008;9(9):

771-783.doi:10.1016/j.jpain.2008.04.007.