The Hidden Barriers to Drug-Free Care

By Sherry McAllister, DC, President, Foundation for Chiropractic Progress

When non-prescribing healthcare providers talk about barriers to delivering care, the discussion usually centers on cost, insurance, insufficient referrals, and lack of education about the benefits of care.  

But there are other relevant obstacles to consider.

Several studies have highlighted how income, race, and accessibility of non-prescribing providers can influence whether back pain patients are prescribed opioids or non-pharmaceutical care.

Managed care company, UnitedHealth Group (UHG), noted that in the American Southeast, back pain was treated with opioids at a higher rate than in other regions. It took a deep dive into the data to examine why. Among its findings:

  • The Southeast has less availability of non-prescribing providers such as doctors of chiropractic (DCs), physical therapists, and licensed acupuncturists. With fewer non-prescribing providers, patients with back pain tend to seek treatment from primary care physicians (PCP) who are able to prescribe opioids.
  • The Southeast generally has lower household adjusted gross income (AGI) and a higher percentage Black population. The region also has high levels of illiteracy and innumeracy.
  • According to the Dept. of Health and Human Services, non-prescribing      musculoskeletal pain management specialties are among the least diverse healthcare professions. Nearly 90% of DCs and nearly 80% of physical therapists are white. The study doesn’t draw conclusions but poses the question of whether this lack of diversity affects the rate at which people of color visit DCs and other providers.
  • Eighteen percent of zip codes in the study had no non-prescribing providers. Those zip codes also had the highest rate of opioid use for back pain, the lowest average AGI and the highest percentage of the non-white population. 

Location and opioid use

All very interesting, but how relevant is it? To find out, researchers zeroed in on Atlanta and found that 58% of zip code variation in opioid prescribing for back pain can be explained by such factors as AGI, race, and accessibility of non-prescribing providers.  

A presentation by David Elton, DC, chief strategy officer for UHG Ventures showed that the more patients start with a non-prescriber (provider) in the zip code, the rate of opioid use goes down. In those same zip codes, the more patients that start with a PCP, the more opioid use goes up.

The personal and financial devastation caused by the overprescribing and abuse of opioids is well documented. While steps have been taken to correct the problem, the crisis is far from over.

A July 2020 report from the American Medical Association found a nearly 40% decline in opioid prescriptions over the past five years, but overdose deaths have continued to increase, largely due to the growing use of illicit drugs, such as synthetic fentanyl.

While the availability of non-prescriptive treatment is not a silver bullet for the opioid crisis, it’s clear it can reduce prescribing while still addressing patients’ pain management needs.

And patients want these types of treatments.

A 2020 survey of chronic pain sufferers by the U.S. Pain Foundation, showed that most patients are not getting access to the integrative and multidisciplinary pain care viewed as most effective. Providers typically most emphasized medications (38.4%) and interventional procedures (26.2%), while patients wish they most emphasized complementary and integrative health (39%), restorative therapies (36.6%), and medications (35.5%).

Cost is the biggest barrier to accessing treatments, including therapies that aren’t covered by insurance or with unaffordable copays or limits on visits. More than three-quarters of respondents indicated cost prevented them from accessing one or more treatment options (76.5%). Cost was the most commonly a barrier to massage (52.8%), acupuncture (39%), physical therapy (29.4%), and chiropractic care (27%).

So, if these treatments are effective in managing pain while avoiding opioids, what can be done to improve their accessibility?



State governments can do much to reduce the barriers to non-opioid care through the management of their state Medicaid rules and the involvement of state public health agencies.

A 2020 report by the National Governors Association Center for Best Practices, stated that it’s not enough for states just to crack down on opioids: “As states continue to monitor and regulate opioid prescribing, it is essential that policymakers promote access to effective pain management, including use of physical, psychological and multimodal pain treatments, as well as non-opioid pharmacologic therapies.” 

It recommended states adopt measures to improve non-opioid pain management. They include: 

  • Studying current evidence, coverage, and access for non-opioid therapies, and nonpharmacologic interventions such as spinal manipulation therapy,* physical therapy, and acupuncture.  *Chiropractic adjustments are a form of spinal manipulative therapy performed 94% of the time by DCs.
    • Exploring coordinated, interdisciplinary care delivery models that function as best practice models for patients experiencing chronic pain. 
    • Changing Medicaid rules to include more chronic pain management services. 
  • Identifying additional state strategies for cross-sector collaboration to support expanded access to care. 

Based on its survey findings, the U.S. Pain Foundation also recommends improvements in the areas of advocacy and policy change, education, and support. These include improving insurance coverage for multidisciplinary therapies, expanding telehealth, and better training of patients and providers in care options. 

Overcoming these barriers seems daunting, but the benefits of doing so can be found in the UHG study of Atlanta. Researchers were puzzled as to why one low-income, primary Black zip code had a drastically lower rate of opioid use than neighboring zip codes with the same demographics. They soon discovered the reason — the practice of a single Black female chiropractor. 

“One provider can make a difference,” Dr. Elton said. “How many zip codes in the U.S. are missing that provider?”

About the author:

Sherry McAllister, DC, is president of the Foundation for Chiropractic Progress (F4CP). A not-for-profit organization with nearly 32,000 members, the F4CP informs and educates the general public about the value of chiropractic care delivered by doctors of chiropractic (DC) and its role in drug-free pain management.

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