Chiropractic + Naturopathic Doctor • June 2017 • Roundup

VANCOUVER – Canadians are increasingly utilizing complementary and alternative medicine – such as chiropractic care, massage therapy, yoga and acupuncture – according to a new survey by the Fraser Institute

“Alternative treatments are playing an increasingly important role in Canadians’ overall health care, and understanding how all the parts of the health-care system fit together is vital if policymakers are going to find ways to improve it,” said Nadeem Esmail, Fraser Institute senior fellow and co-author of “Complementary and Alternative Medicine: Use and Public Attitudes” reports released in 1997, 2006 and 2016.

The 2016 survey involved 2,000 interviews with a randomly selected sample of adults aged 18 and older. Respondents were asked about their health conditions, their use of conventional medical services, and whether they had tried any alternative medicines for their health conditions, the Fraser Institute report said. Survey respondents were also asked about their views on health, health care, medical care and public policy.

The survey found more than three-quarters of Canadians – 79 per cent – have used at least one complementary or alternative medicine (CAM) or therapy some time in their lives. That’s an increase from 74 per cent in 2006 and 73 per cent in 1997, when two previous similar surveys were conducted.

In fact, more than one in two Canadians (56 per cent) used at least one complementary or alternative medicine or therapy in the previous 12 months, an increase from 54 per cent in 2006 and 50 per cent in 1997.

Canadians are using those services more often as well, averaging 11.1 visits in 2016, compared to fewer than nine visits a year in both 2006 and 1997.

The most popular complementary and alternative treatments used by Canadians in 2016 were massage therapy (44 per cent), followed by chiropractic care (42 per cent), yoga (27 per cent), relaxation techniques (25 per cent) and acupuncture (22 per cent.)

In total, Canadians spent $8.8 billion on complementary and alternative medicines and therapies last year, up from $8 billion (inflation adjusted) in 2006.

Interestingly, the survey finds a majority of respondents – 58 per cent – support paying for alternative treatments privately and don’t want them included in provincial health plans. Support for private payment is highest (at 69 per cent) among 35- to 44-year-olds.

“Complementary and alternative therapies play an increasingly important role in Canadians’ overall health care, but policy makers should not see this as an invitation to expand government coverage – the majority of Canadians believe alternative therapies should be paid for privately,” Esmail said.

SAN DIEGO, CALIF. – Surgical approaches to treating tennis elbow may not offer additional benefit to patients, according to research presented at the American Orthopaedic Society for Sports Medicine’s (AOSSM) Specialty Day in San Diego. The study, a randomized, double-blinded clinical trial, explored patient responses to a common surgery aimed at repairing a damaged elbow, compared to a placebo procedure.

The study analyzed 13 patients who underwent surgery to remove a degenerated portion of their extensor capri radialis brevis (ECRB), compared to a group of 13 who received an incision over their lateral elbow and no further repair. Patients included had experienced symptoms of tennis elbow for more than 6 months, and attempted at least two non-surgical treatment approaches such as physical therapy, massage therapy, acupuncture, or splinting/bracing, but had no symptom relief over that period.

“Our data shows both groups experienced significant improvements in pain measures by 26 weeks after surgery, including frequency of pain with activity,” commented lead author Martin Kroslak from the Orthopaedic Research Institute in Sydney, Australia. “Further, these results were consistent or improved after one to four years of follow-up, with no significant difference between the two groups at any point.”

Patients were required to complete questionnaires, indicating symptoms including pain frequency and severity with activity and rest, during sleep, and also difficulty picking up objects or twisting motions. Frequency of elbow pain during activity was the primary outcomes measure for each group. Both groups were treated with the same rehab, including ice application, stretching, and strengthening rehab program within two weeks of surgery. At twoand- a-half-year follow-up, 22 patients completed a questionnaire and 11 returned for exam.

“Managing chronic tennis elbow is a challenge for a large portion of the active population,” noted Kroslak. “Our research demonstrates the challenges in outlining a treatment plan for these patients, and the continued work to be done in developing both surgical and non-operative approaches.”

WINNIPEG – Manitoba Health Minister Kelvin Goertzen says he has met with representatives of the Manitoba Chiropractors Association to talk about future funding.

The province has been hinting for weeks that subsidies for chiropractic services, which cost the government nearly $12 million annually, are going to be reduced.

Under a five-year contract signed by the previous NDP government, chiropractors bill Manitoba Health $12.30 per patient visit, with a maximum of 12 visits per patient subsidized each year.

The contract between the government and the Manitoba Chiropractors Association is set to expire in March 2020, but Goertzen won’t say whether it’s being renegotiated.

An official with the province’s chiropractors’ association will only confirm discussions are taking place with the government.

“We are not opening their contract without their consent, but we’ve had a number of discussions about what that might look like,” said Goertzen.

“There are different things that we could do in-contract and out of contract. But I think the approach that we’ve taken is that we want to do this in a co-operative way.”

The minister noted the government has asked for broad buy-in from the health sector to get spending under control, and chiropractors understand that.

“It’s fair to say the premier has indicated that this is an ‘all hands on deck effort’ to ensure that we have sustainability in the health-care system today, tomorrow and into the future,” he said.

There are currently more than 250 chiropractic doctors in Manitoba. The profession was recently the subject of a CBC News investigative report that highlighted claims made by a handful of chiropractors in Manitoba that are “at odds with public health advice,” the CBC story said.

A source close to the community expressed concern the CBC report nitpicked certain information that do not necessarily represent the views of the majority of chiropractors in Manitoba.

As of this writing, the source confirms the association is still in talks with the government. (Winnipeg Free Press)

UPDATED OPIOID-PRESCRIBING guidelines published recently in the Canadian Medical Association Journal (CMAJ) urge doctors to avoid giving the powerful narcotics as a first-line treatment to patients with chronic, non-cancer pain and instead try other medications or non-pharmaceutical therapies to prevent potential harms associated with the widely used drugs.

Those harms include physical dependence or addiction, as well as the increasingly common risk of fatal overdoses. An estimated 2,000 Canadians died of opioid overdoses in 2015 alone, and initial 2016 data still being tallied suggest the number of fatalities linked to the drugs – both prescription and illicit – could far exceed that figure.

“It really comes down to the paradox of trying to provide important relief for patients dealing with unrelenting chronic pain while at the same time balancing the risks associated with the medications,’’ said Dr. Jason Busse, a researcher at the National Pain Centre at McMaster University and lead author of the 10-recommendation document.

For patients whose chronic pain is not controlled with non-opioid therapy, the panel of experts that developed the guidelines says dosages of opioids like oxycodone, hydromorphone and the fentanyl patch should be restricted to less than the equivalent of 90 milligrams of morphine per day, and ideally to less than 50 mg.

Physicians treating patients already taking the equivalent of 90 mg of morphine or more should consider incrementally tapering their daily intake to the lowest effective dose, and possibly even discontinuing the potent medications, the panel recommends.

The new guideline document, published in May, provides much stronger and more detailed advice than a previous version released in 2010, which suggested doctors could use a “watchful dose” of the equivalent of 200 mg of morphine daily.

“After 2010, there was not the kind of impact on opioid prescribing that I think people were hoping for,” Busse said.

“There was a little bit of a downtick, but maximum doses of opioid prescribing went up, admissions for hospital-related opioid toxicity went up, and death rates have continued to climb as well.”

Moreover, 40 per cent of recipients of long-acting opioids were receiving the equivalent of more than 200 mg of morphine daily, while 20 per cent were getting more than 400 mg.

Dr. Irfan Dhalla, a practising Toronto physician and vice-president of evidence development and standards for Health Quality Ontario, called the new guidelines a “huge improvement.”

Doctors must consider the possibility that patients have become addicted to their medication, or are continuing use of the drugs to avoid the often-debilitating symptoms of withdrawal.

“Many patients being prescribed high-dose opioids in fact have an opioid- use disorder, or an addiction to opioids, and physicians need to be aware of that and work with colleagues to diagnose and treat opioid-use disorder in an evidence-based way,” said Dhalla, who was not involved in developing the guidelines.

But he also said that when it comes to the recommendation to taper the amount of opioids for patients already taking them – especially long-time users – it’s vital that doctors don’t suddenly discontinue the painkillers or rapidly drop the daily dosage for those who truly need the drugs.

Busse agreed there is a danger of an “overcorrection” in prescribing practices, because doctors recognize there’s been a massive increase in cases of opioid toxicity and fatal overdoses over the last 20 years.

He acknowledged there is a subpopulation of Canadians with chronic pain that derive an important benefit from the medications – relief they have been unable to achieve with non-opioid therapies.

“If we attempt to take them off their opioids right away or aggressively taper, many of those patients are going to go into opioid withdrawal and some of those patients if they are denied opioids, if they’re struggling with symptoms of withdrawal, they may feel compelled to seek out opioids from other sources,” Busse said.

In a related CMAJ commentary, Dr. Andrea Furlan of the Toronto Rehabilitation Institute and Dr. Owen Williamson of Monash University in Melbourne, Australia, say the updated guidelines must be supported by a national pain strategy and “evidence- based alternative treatments for the one in five Canadians currently living with chronic pain” from such conditions as back problems, fibromyalgia and arthritis.

“Until we have a national pain strategy, physicians will continue using the only tool they have: their prescription pad,” they wrote.