Among its consequences, the COVID-19 pandemic is an unplanned experiment in what it means to have reduced access to care. Sadly, while it’s occurring, Ontarians’ need for care is rising. This increased need is not directly related to COVID-19 but because of it.

Pandemic’s impact on patients

Ontario Medical Association president Dr. Adam Kassam recently advised that due to restrictions during COVID-19’s three deadly waves, “more than one health care service was not performed for every Ontario resident this year.”[1]

This hugely diminished access to care affected primary care, emergency departments, as well as regulated health care professionals, such as chiropractors, registered massage therapists and physiotherapists, who could have provided relief.

As mentioned in my last post, the pandemic’s demands on essential workers and added stress was high, increasing their risk of injury and need for care. Those in labour-intensive roles also had to keep working in less-than-ideal conditions and in moving to makeshift home offices, knowledge workers faced new challenges. These pandemic-driven demands, stress and challenges exacerbated back pain and other spine, muscle, joint and related nervous system or neuromusculoskeletal (nMSK) conditions.

And as musculoskeletal (MSK) conditions and related pain account for the largest share of global disability burden,[2] there’s no doubt reduced access to care impacted many Ontarians with these issues.

In fact, our members have told us of patients who turned to or increased their use of pain management medications to compensate.

Opioid-related deaths increased by more than 75 per cent

Tragically, the fallout of reduced access to health care and other services is notably evident in the number of monthly, opioid-related deaths in Ontario, which rose by 79.2 per cent between February and December 2020.[3]

Some of these fatalities are pandemic related. Others are indicative of the ongoing crisis. For example, almost one third of opioid-related deaths among employed individuals comprised those in the labour-intensive construction industry both before and after the pandemic started.

More than 50 per cent of opioid users have reported back pain

What may come as a surprise to some is that back pain has been reported in more than half of regular opioid users.[4] It’s also one of the most common diagnoses emergency and family physicians cite for prescribing opioids.[5]

And even though many patients are prescribed opioids for pain, a 2016 systematic review and meta-analysis found that opioid medications provide modest, short-term pain relief for people with chronic back pain but evidence of long-term efficacy is lacking.[6] Fortunately, there’s alternatives.

Manual therapy: a medication-free alternative for low back pain

Over the past 10 years, research has demonstrated that treatments chiropractors provide, such as spinal manipulation and therapeutic exercise programs, can relieve low back, neck, shoulder or other MSK pain. Also, the type of care chiropractors provide is now globally recognized as an evidence-based first and second-line approach for low back pain.[7]

In fact, the 2017 Canadian Guideline for Opioid Therapy and Chronic Non-Cancer Pain recommends therapies without medication, such as spinal or joint manipulation and therapeutic exercise, for treating back and neck pain, as well as knee osteoarthritis, fibromyalgia and severe headaches/migraines. Similarly, Health Quality Ontario suggests that making better use of non-medical treatments to manage acute and chronic pain will reduce the number of people who end up using opioids for the long-term.

This means Ontario’s health care system now has a recognized option for treating low back and other spine, muscle and joint pain, aside from opioids. But this option hasn’t been utilized to its full capacity. This shortfall is due in part to the complexity in the public and private pay components it requires to help all patients, including those most vulnerable.

Success of Ontario’s Primary Care Low Back Pain program

For an extended period, Ontario has monitored utilization of the health system with a goal to appropriately move care from acute care settings and emergency departments into the community. So, successive governments focused on strengthening primary care and interprofessional teams as a way of bringing leading practice and efficient health care models to Ontario.

With the knowledge that MSK conditions could be managed in the community, our association advocated with the provincial government to include chiropractic care in the primary care models it was developing at the time.

These efforts led to it funding seven Primary Care Low Back Pain (PCLBP) pilot sites across the province in 2015. Under this model, interprofessional primary care teams were formed to deliver efficient, co-ordinated and integrated care to vulnerable patients with low back pain via MSK experts, such as chiropractors.

Successful outcomes followed and 83 per cent of patients surveyed after receiving MSK care at one PCLBP pilot site said they now rely less on medication, including opioids, to help manage their low back pain.[8] And the PCLBP program continues today.

However, evolution of the community-based model of care has generally seen primary care models focus on disciplines funded by the public health care system – limiting chiropractors’ potential to bring relief to more patients.

OCA’s Opioid and Pain Reduction Collaborative

With the growing awareness of the opioid crisis, there is a desire for all levels of health care professionals, as well as governments to decrease the burden it creates and research what’s causing it. That research reveals significant links to MSK pain and that, for example, these conditions presenting in emergency departments contribute to patients’ initial access to opioids.

So our Board of Directors had the foresight to prioritize the opportunity for chiropractors to help solve the opioid crisis.

Subsequently, we partnered with the Centre for Effective Practice (CEP) to create the evidence-based Opioid and Pain Reduction Collaborative (‘Collaborative’). It’s designed to help chiropractors, or other manual therapists, co-ordinate a plan of care with patients and their prescribing health care professionals toward the end goal of them successfully reducing their opioid use.

Our solution includes the CEP-developed Manual Therapy as an Evidence-Based Referral for Musculoskeletal Pain clinical tool. It’s designed to inform physicians and nurse practitioners with the best available evidence.

Another key part of this solution is a script to help chiropractors start a conversation with a patient about reducing their opioid dependency. Most importantly, this script enables chiropractors to do so while staying within their professional scope of practice. We also offer fillable forms to help chiropractors share care plans with prescribing health care professionals.

Why interprofessional collaboration is imperative

But chiropractors can’t do this on their own. Interprofessional collaboration is imperative because MSK disability that’s related to opioid dependency involves much more than the pain of sitting or standing for long periods of time. It affects all aspects of a patient’s life, including their work, social interactions, family life, mental health and finances.

Spine, muscle and joint experts, such as chiropractors, can target the cause of the MSK pain and connect to affected areas of the patient’s life. Patients, primary care providers, as well as often social workers and other health care professionals, are also essential for the depth and expertise they bring to the complexity of a patient’s situation.

And to achieve the best outcomes, all care team members who the patient wants connected to their care plan should be aware of what’s happening at each stage.

So, as the patient’s mobility improves, it’s important for their care team to understand what the chiropractor’s next steps are in their plan of care. This understanding helps ensure the physician or nurse practitioner reduce their medication at an aligned pace or closely monitors the patient’s medication, if they are taking on a greater amount of exercise.

This close connection among the care team is needed to ensure the patient’s overall goals, such as reducing dependence on opioids, strengthening their mobility or improving their ability to stay at work, are met.

I believe patients also recognize the value of collaboration, as our research has found many are frustrated with the lack of communication and coordination among health professionals who care for them.[9] 

Key challenge: communicating across public and private care disciplines

One of the challenges we face is communicating across disciplines and at the right points in time. As we move into post-pandemic recovery, we know the publicly funded system will be under tremendous pressure to catch up and with enhanced interprofessional communication, chiropractors can help.

So, for example, when a physician refers a patient to a chiropractor or a chiropractor reaches out to them to discuss a patient’s plan of care, it’s important for them to agree on:

• What the early weeks of care look will look like
• When they’ll circle back with each other

This is a watershed moment for all of us to come together to change the outcomes for Ontarians who depend on opioids to relieve their MSK pain.

Health care community’s response to OCA’s Collaborative

This urgency coincides with a growing interest among family health team providers to know what’s going on with their patients’ care – whether it’s from a chiropractor or another health care professional outside the publicly funded system.

There’s a recognition that an increasing number of patients choose to see chiropractors or health care professionals who are not within the public pay system.

We’ve heard about an increasing number of family physicians and nurse practitioners asking about chiropractic care and providing information about the kind of care practitioners can deliver outside the bundled care systems. And again, with a focus on interprofessional care, they want to be engaged in these conversations.

Not surprisingly, the CEP clinical tool has been accessed more than 2,500 times since the Collaborative launched in June 2020 and some of our members have cited favourable feedback from physicians they’ve shared it with.

How the Collaborative will help Ontarians and Ontario

This collaborative approach empowers public and private health care professionals to achieve better patient outcomes for many Ontarians.

Once we reach a critical level of adoption, we expect to see more Ontarians moving, healthy and able to be a committed part of our workforce.

If we can provide the best MSK care at the right place, which is often outside hospitals, we’ll also help enable our health system to efficiently address the pandemic’s backlog of patient needs. Then our publicly funded system can devote its resources to priorities, such as cardiac and cancer care, that can’t be delivered elsewhere.

Finally, I think there’s an opportunity to further explore the co-ordination of care between the public and private pay system for evidence-based, well-established pathways of care. And low back pain would be one of those.

We know more than 70 per cent of Ontarians have extended health care benefit coverage through their workplace and the impact MSK conditions indirectly have on employers.[10] I think there’s an opportunity to leverage these benefits for the greater good, in terms of how they’re covered.

How can you help?

We launched the evidence-based Collaborative’s tools to our members in 2020 and are providing additional supports, such as this podcast series, to advance their implementation.

You can help by encouraging prescribing physicians and nurse practitioners to use this CEP tool and apply this approach to collaboratively help solve this opioid crisis.

I welcome your thoughts and feedback.

(Please note, this blog will be taking a break in August so you can enjoy your summer but it will be back in September with a focus on extended health care insights.)

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^[1] Kassam, A. (2021, July 4). Doctors’ focus on ‘missing patients’ is just first step in leading the pandemic recovery. Toronto Star.

[2] Vos, T., Lim S.S., Abbafati C., et al. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of disease study 2019. The Lancet, 396:1204–22.

[3] Gomes, T., Murray, R., Kolla, G., Leece, P., Bansal, S., Besharah, J., Cahill, T., Campbell, T., Fritz, A., Munro, C., Toner, L., Watford, J. for Ontario Drug Policy Research Network. (2021) Changing Circumstances Surrounding Opioid-Related Deaths in Ontario during the COVID-19 Pandemic.

[4] Deyo, R.A., Von Korff, M., Duhrkoop, D. (2015). Opioids for low back pain. Thebmj. (350):g6380

[5] Borgundvaag, B., McLeod, S., Khuu, W., Varner, C., Tadrous, M. and Gomes, T. (2018). Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study. CMAJ Open. 6(1): E110-E117

[6] Shaheed, C.A., Maher, C.G., Williams, K.A., Day, R., McLachlan, A.J. (2016). Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 176(7):958-968

[7] Foster, N.E., Anema, J.R., Cherkin, D., Chou, R., Cohen, S.P., Gross, D.P., et al. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 391(10137): 2368–2383.

[8] Primary Care Low Back Pain Pilot Evaluation: Final Report.

[9] Partnership4BetterHealth, OCA Patient and Family Advisory council.

[10] Environics Research, as commissioned by the Ontario Chiropractic Association. (2019). Attitudes of Ontarians Toward Chiropractic Care. 13