INTRODUCTION
Chiropractic care has demonstrated benefit for a variety of clinical conditions through the use of nonsurgical and drugless methods of treatment.1–4 Patients of chiropractors present for care primarily due to low back pain (LBP), neck pain, mid back pain and various other neuromusculoskeletal conditions such as headaches, but also for health maintenance or a general check-up.5 Nonpharmacological treatment is typically recommended initially for musculoskeletal conditions such as low back pain, followed by prudent use of medication, imaging, and surgery if necessary.6–8 While the care provided by chiropractors is nonpharmacologic, patients may also use pharmacological treatment concurrently.
Several studies have examined the relationship between reduced prescription medication use and chiropractic care.9–11 Initial treatment for new onset LBP from chiropractors is linked to greatly reduced use of opioids.10 When accessed as a first-line treatment, chiropractic care may have helped to delay and, in some cases, prevent opioid prescription.12 This is corroborated by evidence that patients with spinal pain who saw a chiropractor had half the risk of filling an opioid prescription11 or reporting an opioid prescription.13 Further, receipt of chiropractic care was associated with a large decrease in opioid prescribing.12 Beyond opioids, adults receiving chiropractic manipulation for newly diagnosed radicular LBP have significantly reduced odds of receiving a gabapentin prescription over a 1-year follow-up compared with those receiving usual medical care.14
A secondary analysis of a US national survey found a significant proportion of chiropractic users received over-the-counter (OTC) medication (35.2%) and/or prescription medication (23.2%) for the same health problem for which chiropractic care was sought.15 Further, 33.8% of these respondents used chiropractic because they considered that medical treatments were not working for their condition.15 It is also germane to consider that patients seeking nonpharmaceutical interventions (such as chiropractic care) may be motivated by a desire to avoid or reduce medication.16,17 In contrast, adults who had never seen a chiropractor were among those most likely to prefer pharmacologic pain treatments.18
Details of the types of medication that chiropractic patients are using and how these medications may change with care both quantitatively and qualitatively remain unclear. While reductions in prescription medications (such as opioids) have been studied more recently, less is known about the nature of reduction in OTC medicine despite their more prevalent use.15 Overall, patient reported outcomes of both OTC and prescription medications, their usage, and extent of change with chiropractic care have been poorly characterized.
We assessed the perspectives regarding medication use and chiropractic care of patients of Ohio State Chiropractic Association (OSCA) chiropractors. We assessed medication use and perspectives alongside chiropractic care, including the classes of medications that have changed with care. We expected that patients of chiropractors would prefer nonpharmacological care where possible and that they would reduce their consumption of both prescription and OTC medication (particularly analgesic and musculoskeletal) with chiropractic care.
Methods
Study Design
Adult patients of OSCA chiropractors (DCs) were invited to participate in an online survey hosted on the Qualtrics platform (Qualtrics Core XM - Qualtrics, Provo, UT). Participants were recruited via flyers posted in the clinic, email communication, and/or verbal invitation by their respective clinicians. Potential participants that were 18 years of age or older, currently a patient of an OSCA member chiropractor, and who had seen their chiropractor at least twice were provided an anonymous link to the survey URL via email or QR code. The URL and QR linked to an informed consent splash page and individuals that provided their electronic consent were then able to access and complete the survey. Chiropractors kept track of how many patients were provided with the link to the survey in order to calculate the response rate. Patients not currently using any medications were also invited to participate. To prevent participants from taking a survey more than once, we used the option in Qualtrics, “prevent multiple submissions”. The survey was available from November 1, 2023 to November 30, 2023 then again from December 15, 2023 to January 15, 2024. The study was approved by Miami University’s Institutional Review Board (#02199r).
Clinician Recruitment
An initial email was sent to all OSCA chiropractors inviting them to help recruit their patients to be a part of the study. The email contained a brief description of the study, eligibility requirements, how they would recruit patients and a request to contact the OSCA to confirm interest in recruitment. In total, 778 emails were sent to DCs with 10 emails that bounced. Four hundred and seventy-three emails were opened. Of these, 37 DCs expressed interest in the study. Twenty interested clinicians were provided with an informational session prior to data collection.
Survey Design
The survey was specifically designed for this study. Four practicing chiropractors and 1 clinician scientist (lead author) contributed to the development of the survey instrument and provided expert appraisal for face and content validity. An additional clinician scientist provided further critique after the initial survey construction. The following survey questions were informed from and adopted or modified from previously published studies: 1,5 2-3,19 6-7,20 9,21 10,22,23 1124,25 and 13.26 The completed survey was estimated to take approximately 5–10 min to complete (see Appendix).
The survey was divided into 3 sections. The first section of the survey (questions A-G) collected information on patient characteristics and demographics including age, sex, height, weight, race, and education level. The second section (questions 1-5) queried respondents’ reasons for currently seeking chiropractic care. It also asked about symptom intensity (today, and worst pain in the past week) using a numerical rating scale (0-10; with anchors no pain and worst pain imaginable), length of time under chiropractic care, and number of chiropractic visits in the last 30 days (text entry). The final section (questions 6-13) asked patients about their use of specific types of OTC and prescription medications, any changes to these medications during chiropractic care, and their views about taking medicine and chiropractic care in general. For each medication that patients indicated was reduced or eliminated, follow-up questions were added regarding individual perceptions of how much chiropractic care had allowed them to reduce that medicine (5-point Likert-style scale: Completely to Not at All).
Data Analysis
Descriptive statistics were compiled for each section of the survey. Total answer counts to each question, means, standard deviations and percentages were computed using Microsoft Excel 365 (Microsoft Corporation, Redmond, WA, USA).
Results
Of the 20 interested OSCA chiropractors attending the information session, 14 invited at least 1 person to complete the survey. A total of 273 patients were provided a link to participate, of which 214 were initialized. Of the 214 initialized, 1 individual did not consent to participate, and 6 participants did not answer any question in the survey beyond agreeing to participate. This left 207 fully completed surveys, for a response rate of 75.8%.
Tables 1 and 2 provide the characteristic and demographic information of patients along with clinical symptoms and experience with chiropractic care. Most patients were female (74%), white (97%), and had at least high-school level education with an average body mass index of 30.6. Most were under care for more than 6 months, averaging 2.8 visits in the past 30 days. Common reasons for visiting a chiropractor were low back (72%), neck (62%) and mid back problems (40%).
Table 3 provides information regarding medication use and chiropractic care. Most patients in our sample reported a reduction or elimination of OTC medication (73%), with fewer reporting reduction or elimination of prescription medication (34%). Some patients did not use OTC’s (16%) or prescription (44%) medications prior to care and still did not use them at the time of the survey. Nearly 70% of patients rated moderate to complete reduction in overall medication use. Non-steroidal anti-inflammatory drugs (NSAIDs) were frequently reduced or eliminated with care (62%), followed by acetaminophen (43%), topical medicines (19%), muscle relaxers (16%) and opioids (5%). Almost 15% stated that reduction of overall medication use with chiropractic care was not applicable. Figure 1 shows the patient reported reduction by percentage for each class of medication.
Patients overwhelmingly agreed or strongly agreed that they prefer not to take any medicine if they can avoid it (94%), and that chiropractic care both improves their quality of life and protects them from getting worse (97%). Since beginning chiropractic care, nearly 95% described their change as much improved or very much improved.
Discussion
Patients in this study self-reported reductions in both OTC and prescription analgesic and musculoskeletal medication usage with chiropractic care. We found the majority of patients rated moderate to complete reduction in overall medication use. Most patients reduced or eliminated OTC medications, with some reducing or eliminating prescription medications.
The CDC Clinical Practice Guideline for Prescribing Opioids for Pain recommends maximizing nonpharmacological and nonopioid therapies for pain.27,28 However, previous work has found 10.7% of U.S. adults used one or more prescription pain medications (opioid or nonopioid) in the past 30 days29 and that 1 in 4 adults used OTC pain relievers for chronic pain management.28 Despite the effectiveness of nonpharmacological treatments for pain, overuse of pharmacological treatment and underuse of nonpharmacological treatment are common among persons with LBP.30
Interestingly, 94% of our sample preferred not to take any medicine if they could avoid it, and nearly 70% of patients reported moderate to complete reduction in overall medication use with chiropractic care. Based on preference and initial indications from this study, chiropractic care may be an effective tool in reducing medication use for those specifically desiring to take less medication, but suffering from musculoskeletal conditions. Similarly, the overwhelming preference of the patients in this survey against taking medication could suggest that patients seeking chiropractic care are distinct as a patient population than those seeking care from medical primary care providers. This is supported by Beliveau et al1 and Glasziou et al,31 suggesting medical and chiropractic patients may be seeking care for markedly different reasons. This contrast is not well understood, and to our knowledge there has been no direct comparison as of yet, but future research should undoubtedly explore this further.
It is possible that patients may seek chiropractic care due to symptoms brought on by the side effects of prescription drugs.32 Ubiquitous use of medication is of great concern as analgesics (both prescription and OTC) can have significant adverse side effects.33 Notably, the risk of an adverse drug event was significantly lower among recipients of chiropractic services.34 It should also be noted that patients under chiropractic care are encouraged to engage in a variety of therapies aligned with their preferences and motivation.35 While it was unclear what aspect(s) or synergies of care delivered the most benefit, previous work has found a significant decrease in medication use in patients who undergo manual manipulation treatments.36 To this end, further work should be conducted to elucidate any potential interactions between the various physical and cognitive interventions employed in chiropractic clinics regarding medication usage.
A recent study in the Lancet36 indicated that paracetamol (acetaminophen) and systemic glucocorticoids not be recommended for LBP, that NSAIDs are second-line or adjunctive therapies, and muscle relaxants should be limited for acute LBP and that insufficient evidence exists for use in chronic LBP. If the patients in our study were taking these medicines for LBP particularly (72% reported seeking care for a lower back problem), it is likely at least some – if not many – of these cases would be incongruent with current recommendations. While we do not know the exact rationale for these patients taking the medicines they were, evidence suggests that general practitioners’ analgesic recommendations for spinal pain have become increasingly divergent from guideline recommendations over time.37 We suggest future studies explore the rationale for why patients of chiropractors choose the medications they do.
Nearly 70% of respondents rated moderate to complete reduction in total medication usage. The potential underlying mechanism for this cessation is not clear from this study, though a number of possibilities or mechanisms may exist. Chiropractic care nearly universally includes spinal joint manipulation and often incorporates lifestyle measures such as nutrition and exercise guidance.38 Chiropractic manipulation,4,39–42 exercise, and nutrition have each demonstrated benefits in reducing pain and inflammation as well as improving overall quality of life.4,39–42 It is possible that these factors (in isolation or combination) could have facilitated the stated decreases in medication usage; however, additional research is needed to examine these modalities in specific patient populations and with regard to particular medication usage. It is also possible that contextual or lifestyle factors may have played a role.43 Further work is needed in these domains – not only to elucidate individual responses to each treatment option, but also to examine how interactions and combinations of care may affect the parameters examined in this study.
This survey is not without limitations, and we urge readers to exercise due caution in interpretation. The nature of this survey precludes any causal understanding of the relationships between, or effects on the variables examined. While the decreases in analgesic and musculoskeletal medication usage here are promising, this survey does rely on self-reported outcome measures. Similarly, recall and social desirability biases (patients were recruited by their chiropractor) are always possible in a study of this design. That being said, study chiropractors attended an informational session led by the lead author to limit possible biases in recruitment. Anonymous links were used and respondents were informed that care could not be affected by individual responses. Exclusion criteria were also minimized to afford maximal participation. Readers should also note that all the respondents in this survey were drawn from OSCA-affiliated clinics in Ohio. Though this was by design, these findings may not generalize to non-OSCA-affiliated clinics and/or other locations. However, this work provides a simple survey template that can easily be reproduced in other locales, as well as at scale.
It is also important to note the survey was limited to a subset of medications and most pertained to musculoskeletal issues. These medications were chosen based on clinical experience (of what most patients present with to our practices) and these medications relate mostly to conditions commonly seen in chiropractic clinics. While the medication reduction mostly affected NSAIDs and acetaminophen, several other types of medication were also impacted (e.g., antidepressants, muscle relaxers, corticosteroids). Chiropractors as well as researchers may wish to query for changes in other types of medications beyond those typically used for pain and anti-inflammatory effects.
The findings of this study provide a catalog of patient self-report on the potential interaction between chiropractic care and primarily analgesic and musculoskeletal medication usage. It additionally raises a number of subsequent questions regarding medication usage and preferences amongst patients seeking chiropractic care. Future research should consider examining chiropractic patient adherence to current medication usage guidelines, patient tapering of medication once under care, as well as seeking greater resolution regarding what classes of medication are affected most.
Conclusion
This survey provides a sampling of patients seeking care in OSCA-affiliated clinics. The majority of surveyed patients reported reduced overall analgesic and musculoskeletal medication usage with chiropractic care. More patients were able to reduce OTC medicine than prescription medicine. Ninety-four percent of our sample preferred not to take any medicine if they could avoid it. Similarly, 97% of patients agreed or strongly agreed that chiropractic care both improved their quality of life and protected them from getting worse. Musculoskeletal medication usage by chiropractic patients is potentially divergent from current recommendations and tapering strategies are unclear. Prospective study designs including randomized trials are required to confirm the findings and explore the numerous questions raised from this cross-sectional survey.
Abbreviations
OSCA: Ohio State Chiropractic Association
LBP: Low back pain
NSAIDs: Non-steroidal anti-inflammatory drugs
Ethics approval and consent to participate
Ethical approval to conduct this study was granted by the Institutional Review Board at Miami University (#02199r). Patient consent was obtained electronically through Qualtrics prior to the start of the survey.
Funding
No funding was obtained for this study.
Acknowledgements
The authors would like to thank Katie Pohlman, DC, PhD for providing expert review of our survey instrument.
Disclaimer/Conflicts of Interest
All authors are chiropractors. DS, PE and AM are volunteer members of the OSCA Public Health Committee. BS receives a salary from the OSCA in her role as Executive Director of the association. DS is a member of the editorial board of JCC and was not involved in the peer review or decision-making process for this manuscript.