Chiropractic care is popular for low back pain, but may increase the risk for acute lumbar disc herniation (LDH). Low back pain is a common early (prodromal) symptom of LDH and commonly precedes LDH diagnosis. Our objective was to investigate the association between chiropractic care and acute LDH with early surgical intervention, and contrast this with the association between primary care physician (PCP) care and acute LDH with early surgery.
Hincapié, C.A., Tomlinson, G.A., Côté, P. et al. Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study. Eur Spine J27, 1526–1537 (2018). https://doi.org/10.1007/s00586-017-5325-y
Today the Centers for Medicare & Medicaid Services (CMS) finalized a decision to cover acupuncture for Medicare patients with chronic low back pain. Before this final National Coverage Determination (NCD) reconsideration, acupuncture was nationally non-covered by Medicare. CMS conducted evidence reviews and examined the coverage policies of private payers to inform today’s decision.
“Expanding options for pain treatment is a key piece of the Trump Administrations’ strategy for defeating our country’s opioid crisis,” said HHS Secretary Alex Azar. “President Trump has promised to protect and improve Medicare for our seniors, and deciding to cover this new treatment option is another sign of that commitment. Medicare beneficiaries will now have a new option at their disposal to help them deal with chronic low back pain, which is a common and sometimes debilitating condition.”
The decision regarding coverage takes into account an assessment of benefits and harms and the opioid public health crisis. While a small number of adults 65 years of age or older have been enrolled in published acupuncture studies, patients with chronic low back pain in these studies showed improvements in function and pain. The evidence reviewed for this decision supports clinical strategies that include nonpharmacologic therapies for chronic low back pain. CMS notes too that while there is variation in covered indications and frequency of services, a number of large private payers provide some coverage of acupuncture for certain indications.
“We are dedicated to increasing access to alternatives to prescription opioids and believe that covering acupuncture for chronic low back pain is in the best interest of Medicare patients,” said CMS Principal Deputy Administrator of Operations and Policy Kimberly Brandt. “We are building on important lessons learned from the private sector in this critical aspect of patient care. Over-reliance on opioids for people with chronic pain is one of the factors that led to the crisis, so it is vital that we offer a range of treatment options for our beneficiaries.”
In 2017, opioids were involved in 47,600 deaths related to overdose. CMS is keenly focused on fighting the opioids epidemic including by supporting access to pain management using a safe and effective range of treatment options that rely less on prescription opioids, including non-pharmacological approaches. In addition to today’s announcement, CMS has made significant strides in preventing opioid use disorder, such as issuing safety alerts to pharmacists when a beneficiary’s opioids prescription exceeds certain levels. Given these and other efforts from federal partners, total opioids dispensed by pharmacies nationwide declined 31 percent since 2017.
Acupuncture is a treatment in which practitioners stimulate specific points on the body, most often by inserting thin needles through the skin. As with other complex diseases, CMS recognizes the importance of having treatment options which allow for an integrated approach that is tailored to the needs and preferences of Medicare patients. Today’s decision will cover up to 12 sessions in 90 days with an additional 8 sessions for those patients with chronic low back pain who demonstrate improvement.