A recent large and comprehensive review of the chiropractic profession establishes that 93% of patients initially go to chiropractors for spine pain complaints (1). The same review documents that chiropractic care is exceptionally effective and safe for these spine pain patients.

As a consequence of the effectiveness and safety of chiropractic care for spine pain patients, more and more practice guidelines are advocating for the use of spinal manipulation as the initial intervention for the management of spinal pain syndromes (2, 3, 4, 5). Yet, pharmaceuticals continue to have a substantial influence in the management of pain as a consequence of financial influence, marketing, and control of publication and education (6).

The theme of this publication is to review credible studies comparing chiropractic care (specific line-of drive spinal manipulation) to these commonly prescribed drugs:

• Acetaminophen (best known brand name is Tylenol)
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Opioids
• Benzodiazepine
• Gabapentin

Acetaminophen

Acetaminophen (paracetamol) is a pain reliever found in many products. In the United States, the best-known brand name for acetaminophen is Tylenol.

In 2017, the European Journal of Pain published a study titled (7):

Clinical Practice Guidelines for the Noninvasive Management of Low Back Pain

The authors performed an extensive search of Low Back Pain Guidelines published between 2005 and 2014. Their conclusions include:

“Most high-quality guidelines target the noninvasive management of nonspecific low back pain and recommend education, staying active/exercise, manual therapy, and paracetamol [acetaminophen] or NSAIDs as first-line treatments.”

“However, the endorsement of paracetamol [acetaminophen] for acute low back pain is challenged by a recent high-quality randomized controlled trial and systematic review; therefore, guidelines need updating.”

The use of acetaminophen has fallen into disfavor in the treatment of low back pain as a consequence of a number of published studies. As an example, in 2014, the journal Lancet published a study titled (8):

Efficacy of Paracetamol for Acute Low-Back Pain:
A Double-Blind, Randomised Controlled Trial

In this multicenter trial, patients with acute low-back pain were followed for 3 months. The authors note:

Guidelines for acute low-back pain universally recommend paracetamol [acetaminophen] as the first-line analgesic; “No direct evidence supports this universal recommendation.”

“Although guidelines endorse paracetamol for acute low-back pain, this recommendation is based on scarce evidence.”

“Neither regular nor as-needed paracetamol improved recovery time or pain intensity, disability, function, global change in symptoms, sleep, or quality of life at any stage during a 3-month follow up.”

The results of this study “suggest that simple analgesics such as paracetamol might not be of primary importance in the management of acute low-back pain, and the universal recommendation in clinical practice guidelines to provide paracetamol as a first-line treatment should be reconsidered.”

“Our results convey the need to reconsider the universal endorsement of paracetamol in clinical practice guidelines as first-line care for low-back pain.”

 In 2015, a study was published in the British Medical Journal titled (9):

Efficacy and Safety of Paracetamol for Spinal Pain and Osteoarthritis:
Systematic Review and Meta-Analysis of Randomised Placebo Controlled Trials

The authors performed a systematic review and meta-analysis of randomized controlled trials found in multiple medical databases. The evidence presented in the article is considered to be of “high quality.” These authors note:

“[Our results confirm the] conclusion that paracetamol does not deliver a clinically important benefit for spinal pain and osteoarthritis.”

“There was ‘high quality’ evidence that paracetamol is ineffective for reducing pain intensity and disability or improving quality of life in the short term in people with low back pain.” 

“Paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis.”

“Our results therefore provide an argument to reconsider the endorsement of paracetamol in clinical practice guidelines for low back pain and hip or knee osteoarthritis.”

Nonsteroidal Anti-inflammatory Drugs

Nonsteroidal Anti-inflammatory Drugs (NSAIDs) are the most commonly used category of drugs for the treatment of pain, including low back pain. They are available over-the-counter and/or by prescription. Common category/brand names for NSAIDs include aspirin, ibuprofen, Motrin, Naprosyn, etc.

In 2003, a study was published in the journal Spine titled (10):

Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation

The spinal manipulation was performed by chiropractors (2 visits per week). The acupuncture was performed by experienced acupuncturists (2 visits per week). The drugs used were prescription NSAIDs (daily use).

The study involved 115 patients. The primary assessment tools used were the Oswestry Back Pain Disability Index, the Neck Disability Index, the Short-Form-36 Health Survey questionnaire, and a visual analog scale for pain intensity. The clinical trial lasted for 9 weeks.

The proportion of primary care patients with uncomplicated spinal pain who have poor outcomes is higher than generally recognized. Adverse reactions to NSAIDs are well documented, including gastrointestinal toxicity, which is “one of the most common serious adverse drug events in the industrialized world.” There is “insufficient evidence for the use of NSAIDs to manage chronic low back pain.” The authors made these conclusions:

“The highest proportion of asymptomatic patients before or at the week 9 assessment was found in the manipulation group followed by the acupuncture group and the medication group.” 

“Manipulation yielded the best results over all the main outcome measures.”

“Medication apparently did not achieve a marked improvement in chronic spinal pain and caused adverse reactions in 6.1% of the patients. The adverse symptoms disappeared once medication was stopped.”

“In summary, the significance of the study is that for chronic spinal pain syndromes, it appears that spinal manipulation provided the best overall short-term results, despite the fact that the spinal manipulation group had experienced the longest pretreatment duration of pain.”

The authors of this study (10) published a 1 year long-term follow-up in 2005. It appeared in the Journal of Manipulative and Physiological Therapeutics, titled (11).

Long-Term Follow-up of a Randomized Clinical Trial  Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes

The authors concluded:

“Patients who have chronic mechanical spinal pain syndromes and received spinal manipulation gained significant broad-based beneficial short-term and long-term outcomes.”

“In patients with chronic spinal pain syndromes, spinal manipulation may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.”

“Medication apparently did not achieve an improvement in chronic spinal pain.”

Opioids

In 2017, the United States’ problem with opiates/opioids was quantified in the journal Annals of Internal Medicine in a study titled (12):

Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults

This survey used 51,200 adult subjects. The authors found:

• 8 million (37.8%) U.S. civilian, non-institutionalized adults used prescription opioids.
• 5 million adults misused opiate drugs (12.5%).

The authors note that the numbers they present underrepresented the opioid problem because they did not include an assessment of groups that are likely to take and to abuse these drugs, including homeless persons who were not living in shelters, active-duty military personnel, and anyone in jail or other institutions.

The first randomized controlled trial to evaluate opioids for chronic pain was published in 2018, long after the magnitude and seriousness of the opioid crisis was recognized by all players. It was published in the Journal of the American Medical Association, titled (13):

Effect of Opioid vs Non-opioid Medications on Pain-Related Function in Patients with Chronic Back Pain or Hip or Knee Osteoarthritis Pain:

This study involved 234 subjects. The authors state:

“Rising rates of opioid overdose deaths have raised questions about prescribing opioids for chronic pain management.”

“Because of the risk for serious harm without sufficient evidence for benefits, current guidelines discourage opioid prescribing for chronic pain.”

“Studies have found that treatment with long-term opioid therapy is associated with poor pain outcomes, greater functional impairment, and lower return to work rates.”

“Treatment with opioids was not superior to treatment with non-opioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”

In 2023, a study published in the journal The Lancet, titled (14):

Opioid Analgesia for Acute Back Pain and Neck Pain (the OPAL Trial):
A Randomised Placebo-controlled Trial

This is the first placebo controlled randomized controlled trial looking at opioids for acute spinal pain. The study involved 151 participants in the opioid group and 159 in the placebo group. The authors found that being prescribed an opioid for acute spinal pain actually increased the patient’s pain at both the 26- and 52-week follow-up assessment. In other words, not only did the opioid not work, it actually worsened the patient’s pain in the long term. The authors made these observations:

“Low back pain and neck pain are very prevalent, with low back pain being the largest contributor to years lived with disability globally, and neck pain being the fourth largest.”

“Opioid analgesics are commonly used for acute low back pain and neck pain, but supporting efficacy data are scarce.”

“The use of opioids for the management of acute low back pain and neck pain is not supported by direct and robust evidence.”

“This study found there was no benefit of an opioid compared with placebo in people receiving guideline care for acute non-specific low back pain or neck pain.”

“Our findings say that not only are opioids not going to benefit individuals with back and neck pain, but they might also cause worse outcomes even after short-term judicious use.”

“Our findings show that even judicious, short-term use of an opioid conferred no benefits in pain reduction and led to a small increase in pain at the medium-term and long-term compared with placebo.”

“There is no evidence that opioids should be prescribed for people with acute non-specific low back pain or neck pain.”

“Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo.”

These authors explain that clinical practice guidelines for physicians that advocate for the judicious use of opioids for acute spinal pain syndromes are erroneous and that they should be changed. They note that their study shows no benefit, risks of harms, risks of misuse, and increased risk of long-term pain. As such, they support a shift in the focus of practice guideline for spinal pain management from pharmacological to non-pharmacological treatments. These non-pharmacological treatments endorse spinal manipulation.

In 2018, a study was published in The Journal of Alternative and Complementary Medicine, titled (15):

Association Between Utilization of Chiropractic Services  for Treatment of Low-Back Pain and Use of Prescription Opioids

The authors analyzed the health insurance claims of 6,868 low back pain subjects, noting:

“There is little evidence that opioids improve chronic pain, function, or quality of life.”

“Among U.S. adults prescribed opioids, 59% reported having back pain.”

“The adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower for recipients of services provided by doctors of chiropractic compared with non-recipients.”

“Pain management services provided by doctors of chiropractic may allow patients to use lower or less frequent doses of opioids, leading to lower costs and reduced risk of adverse effects.”  

“Pain relief resulting from services delivered by doctors of chiropractic may allow patients to use lower or less frequent doses of opioids, leading to reduced risk of adverse effects.”

Also, in 2018, the journal Pain Medicine published a study titled (16):

Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs [VA] Chiropractic Care

The authors are from Yale School of Medicine, School of Medicine Boston University, and University of Massachusetts Medical School. The VA began providing chiropractic services on-site in 2004 and has expanded implementation each year thereafter. In the VA, chiropractic patients are seen overwhelmingly for low back and/or neck musculoskeletal pain conditions. The authors note:

“Apart from the potential to reduce pain and improve function in patients with musculoskeletal conditions, chiropractic care may have an impact on opioid use in such patients.”

“Chiropractic care is more likely to be a replacement for, rather than an addition to, opioid therapy for chronic musculoskeletal pain conditions in the VA.”

In 2019, a study was published in the journal BMJ Open titled (17): 

Observational Retrospective Study of the Initial Healthcare Provider for New-onset Low Back Pain with Early and Long-term Opioid Use

The authors examined the association of initial conservative therapy provider treatment (chiropractors, acupuncturists, physical therapists) on opioid use in a national sample (216,504) of individuals with a new-onset low back pain. The most frequent initial conservative provider seen was a chiropractor. The authors note:

“For early opioid use, patients initially visiting chiropractors had 90% decreased odds [of early opioid use].”

“Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids.”

In 2020, a study was published in the journal Pain Medicine titled (18):

Association Between Chiropractic Use and  Opioid Receipt Among Patients with Spinal Pain

The authors are from Yale School of Medicine. This meta-analysis used 62,624 patients from 6 chiropractic studies. The authors note:

“Chiropractors predominantly manage spinal conditions, with back conditions being the most common reason to seek chiropractic care.”

“The main finding of the review was that all included studies demonstrated a negative association between use of chiropractic care and opioid prescription receipt.”

“Chiropractic users had 64% lower odds of receiving an opioid prescription than nonusers.”

In 2020, a study was published in the journal Pain Medicine titled (19):

Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain

The objective of this study was to evaluate the impact of chiropractic utilization upon use of prescription opioids among 101,221 patients with spinal pain. The authors note:

“Among patients with spinal pain disorders, for recipients of chiropractic care, the risk of filling a prescription for an opioid analgesic over a six-year period was reduced by half, as compared with non-recipients.”

“[There is] accumulating evidence for increased utilization of chiropractic services as an upstream strategy for reducing dependence upon prescription opioid medications.”

In 2022, a study was published in the Journal of Chiropractic Medicine, titled (20):

Associations Between Early Chiropractic Care and Physical Therapy on Subsequent Opioid Use Among Persons with Low Back Pain

This study assessed 40,929 patients with low back pain, noting:

“The use of chiropractic care within 30 days of LBP diagnosis was associated with diminished use of opioids in the short term and, in particular, the long term, in which the risk of long-term opioid use was almost cut in half.”

“Chiropractic care was associated with substantial reduction in likelihood of any opioid use and long-term opioid use [by 44%].”

Also, in 2022, a study was published in the journal Chiropractic & Manual Therapies, titled (21):

Association Between Chiropractic Care and Use of Prescription Opioids Among Older Medicare Beneficiaries with Spinal Pain

This retrospective observational study examined 55,949 Medicare beneficiaries diagnosed with spinal pain. The authors noted:

“The adjusted risk of filling an opioid prescription within 365 days of first office visit was 56% lower among [chiropractic] recipients as compared to nonrecipients.”

Among early recipients of chiropractic care, the reduction of filling an opioid prescription was 62% lower as compared to non-recipients.

“Among older Medicare beneficiaries with spinal pain, use of chiropractic care is associated with significantly lower risk of filling an opioid prescription.”

Benzodiazepine

In 2022, a study was published in the journal BMJ Open, titled (22):

Association Between Chiropractic Spinal Manipulative Therapy and Benzodiazepine Prescription in Patients with Radicular Low Back Pain

Benzodiazepines (BZDs) are a class of medication that are increasingly prescribed for patients with low back pain (LBP). They are particularly commonly used in patients with radicular LBP (rLBP).

This was the first study to examine the association between chiropractic spinal manipulative therapy (CSMT) and subsequent benzodiazepine prescription. There were 9,206 patients in each cohort with a mean age of 38 years (range 18-49 years). Outcomes were measured at 3, 6, and 12 months. The authors’ initial hypothesis was that adults receiving chiropractic care for new diagnosis of radicular LBP would have reduced odds of receiving a benzodiazepine drug. The authors made these observations:

• The number of physician visits during which BZDs were prescribed for back pain in the USA more than tripled from 2003 to 2015.
• In a 2018 survey, 27% of low back pain patients reported being recommended BZDs by a medical doctor in the previous 12 months.
• “Adverse effects of BZDs include sedation, addiction and increased risk of suicide.”
• “There is an increased risk of fatal, accidental overdose with concurrent use of BZDs and opioids.”
• BZDs are a risk factor for motor vehicle collisions, falls and associated injuries, which may be explained by BZD-related psychomotor, balance, and cognitive impairment.
• “Although BZDs are increasingly prescribed for LBP, there is no strong evidence supporting their use for this condition.”

Pertaining to chiropractic care, the authors noted:

• “Chiropractors are portal-of-entry providers that treat a variety of musculoskeletal conditions, the most common of which is LBP.”
• Chiropractors use non-drug treatments for patients with rLBP.
• The most common treatment chiropractors employ is spinal manipulative therapy (SMT), which involves high-velocity, low-amplitude thrust, and low-force non-thrust or mobilization.
• “In a 2019 survey, U.S. chiropractors reported managing radiculopathy at least once per week.”
• “SMT may relax hypertonic (abnormally tight) muscles, or release adhesions surrounding the lumbar disc or facet joints, leading to improved range of motion in those with rLBP.”
• “Systematic reviews have found evidence supporting [SMT] treatment for acute, chronic and radicular LBP, while documenting its safety.”

Pertaining to Clinical Practice Guidelines (CPGs), the authors note:

• “Insufficient evidence supporting the efficacy of BZDs for LBP and the risk of serious adverse events has led clinical practice guidelines to discourage their use for this condition.”
• “Recent CPGs from the National Institute for Health and Care Excellence (2020), Veterans Affairs/Department of Defense (2019), Global Spine Care Initiative (2018) and Belgian Health Care Knowledge Centre (2017) recommended against prescribing BZDs for LBP while those of the Am. College of Physicians (2017) concluded there was insufficient evidence for their effectiveness in acute or subacute LBP.”

The authors made these conclusions:

• “This study identified a significant reduction in odds of BZD prescription over 3-month, 6-month and 12-month follow-up windows in adults initiating care for rLBP with CSMT.”
• “These results reinforce the use of CSMT as a first-line non-pharmacological option for adults with rLBP.”
• “These findings suggest that receiving CSMT for newly diagnosed rLBP is associated with reduced odds of receiving a benzodiazepine prescription during follow-up.”

Gabapentin

In 2023, a study was published in the journal BMJ Open, titled (23):

Association Between Chiropractic Spinal Manipulation and Gabapentin Prescription in Adults with Radicular Low Back Pain

This study was the first to examine the association between chiropractic spinal manipulative therapy (CSMT) and the likelihood of gabapentin prescription among patients with radicular low back pain (rLBP). Study participants were adults aged 18–49 who were having their first episode of rLBP diagnosis. Eligible patients were from 77 healthcare organizations:

• There were 1,635 patients in the CSMT cohort.
• There were 1,635 patients in the gabapentin cohort.

Low back and neck pain account for the leading cause of medical expenditures in the U.S. The U.S. has the leading prevalence of low back pain in the world. Radicular low back pain (rLBP) involves a nerve root lesion and has symptoms that radiate into the ipsilateral lower extremity.

• “Gabapentin has been used off-label to treat neuropathic symptoms of LBP, namely rLBP.”
• “Systematic reviews in 2018 and 2022 demonstrated clear evidence of lack of its effectiveness [gabapentin] for rLBP.” (emphasis added)
• There is growing evidence of risks associated with gabapentin use, including abuse, misuse, dependence, and withdrawal. Other deleterious adverse effects of gabapentin include somnolence (excessive sleepiness), dizziness, ataxia, fatigue, and new-onset asthenic (weakness or lack of energy) symptoms.
• “Several clinical practice guidelines do not recommend gabapentin for the treatment of LBP or rLBP, including those of the American Family Physician.”
• “Despite the paucity of evidence, and in contrast to clinical guideline recommendations, gabapentin continues to be commonly prescribed for LBP.”

Pertaining to chiropractic, the authors made these observations:

• “Chiropractors are portal-of-entry providers in the USA who frequently treat spinal disorders.”
• “While US chiropractors are portal-of-entry providers, they do not prescribe medications, including gabapentin.”
• When treating rLBP, chiropractors use “spinal manipulative therapy (CSMT), a hands-on treatment directed to the joints of the spine.”
• CSMT is supported by systematic reviews and recommended by clinical practice guidelines for the treatment of LBP and rLBP.

The authors made these conclusions:

• “After matching, odds of gabapentin prescription over the 1-year follow-up were significantly lower in the CSMT cohort compared with the cohort receiving usual medical care,” by 47%.
• “These real-world findings support our hypothesis that adults initially receiving CSMT for rLBP have reduced odds of receiving a gabapentin prescription over a 1-year follow-up period.”
• “Our findings are consistent with some authors’ recommendations that patients with LBP/rLBP should initiate treatment with non-pharmacological providers such as chiropractors.”

Summary

The studies reviewed here share a central theme: acetaminophen, NSAIDs, opioids, benzodiazepine, and gabapentin do not work well for pain control. Yet, providers and patients often do not understand this. Doctors routinely prescribe these drugs for pain, and patients willingly take them. In addition to not working very well, long-term use is associated with many harmful side effects.

These studies also show that chiropractic care for spine pain syndromes is effective, safe, and is associated with meaningful reductions in the use of these pharmacological products, ultimately avoiding harmful side effects.

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