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Journal of Chiropractic Volume XXVII, Issue 2 Mar/Apr 2012

TCA Victory in the Third Court of Appeals! Control the Five “Rs” of Rehab Training TBCE Adopts Final Amendments to Rule 75.1 Gross Unprofessional Conduct TBCE Adopts New Rule 71.13, Chiropractic Specialties TBCE Proposes Amendment to 77.2 Publicity TBCE Proposes Amendment to Rule 71.15, Recognized Specialties TBCE Proposes Amendment to Rule 75.2, Proper Diligence and Efficient Practice of Chiropractic The Drug Problem Chiropractic Indy Car


Registration Application Register online at www.chirotexas.org OR fax completed form to 512-477-9296 OR Mail to Texas Chiropractic Association, 1122 Colorado St., Ste. 307, Austin, TX 78701 Please type or print clearly. Please use one form per doctor. Doctor’s Name _____________________________________ License # ________________ Spouse/Guest’s name __________________________ CA Name(s) _____________________ Mailing Address: ______________________________ City/State/Zip ____________________ Phone ___________________ Fax _______________ Email ___________________________ Registration includes required 8 hrs. Medicare, 4 hrs. Ethics, Coding, Risk Mgmt. & Coding plus additional 4 hrs. CE or 12 hrs. Acupuncture.

Early Registration – by May 31, 2012 Member Doctor $275 ___ Nonmember Doctor $400 ___ Medicare & Ethics only* $175 ___ CA* $100*___ Chiropractic Student* $50 ___ Spouse/guest $175 ___ Retired (meals extra, pls. call)$ 0* ___

Late & On-Site Registration after May 31 Member Doctor $375 ___ Nonmember Doctor $500 ___ Medicare & Ethics only* $275 ___ CA* $200*___ Chiropractic Student* $75 ___ Spouse/guest $175 ___ Retired (meals extra, pls. call)$ 0 ___

Full registration includes Opening Reception, Presidential (closing) Banquet, breakfasts, breaks, (1) lunch. Additional Presidential Banquet tickets are $75 each. _____ Additional luncheon tickets are $45 _____ *This registration does not include the Opening Reception or Presidential Banquet.

Payment Method: Check is enclosed for $_______ Credit Card charge for $___________ Card Number ___________________________________________ Exp _______________ Name on Card ______________________________________________________________ Signature __________________________________________________________________ Cancellation Policy: All conference registration cancellations received by the TCA office by May 24, 2012 will be honored and fees will be refunded following the conference less a $50 administrative fee. Refunds will not be made for no-shows. By registering for the Convention you are agreeing to TCA’s use of any photos taken during the event for marketing purposes. If you have a disability or require special assistance, please call TCA at 512-477-9292.


TCA CONVENTION JUNE 7-9

Dr. Kim Christensen DC, DACBR, CCSP, DSCS, CES, PES

Platinum Sponsor We have invited some of the state’s most knowledgeable and respected practitioners to speak. With one seminar you can fulfill your continuing education, Medicare and Ethics required TBCE hours. We also have sessions showcasing  practical technique and chiropractic trends. We invite you to come, listen, learn and network with your colleagues from across the state at the greatest chiropractic event in Te x a s i n 2012. Come and enjoy the sights, tastes and sounds of the music capital of the world, Austin. TCA Convention headquarters are the downtown the Sheraton Austin. Come experience the bats, paddle Ladybird Lake, play some golf or just enjoy live music on 6th street after the sessions.

Dynamic Spine Stabilization provides advance knowledge and skills to successfully work with patients suffering from musculoskeletal impairments, imbalances or post-rehabilitation concerns.

Christopher Kent DC, JD Learn how chiropractic care improves health, saves money enhances quality-of-life and how scientific research supports chiropractic care.

Dr. Matthew H. Sweat DC, BCAO Everything you wanted to know about Atlas Orthogonal Chiropractic – an introduction, its History, Biomechanics, Research, Testimonials, X-Ray and published articles.

Dr. Brandon Brock DC, NP-C Current neurological, physiological and immunological disease mechanisms, how receptor and nutrition based therapy can have a positive impact on various pathologies.

Susan McClellan Medicare Made Simple--This comprehensive training seminar has been designed specifically for Doctors of Chiropractic and their staff and provides the most accurate and current information available to help you get it right

Mark L. Hanson DC, Lac Treatment Protocols for Allergies & Auto-immune Diseases and Special Treatment Techniques for the Back Shu Points.

Larry Montgomery, DC Ethics, Risk Management, Documentation and Coding, TBCE Required Hours


Call for Keeler Award Nominations Established in 1934 by Dr. Clyde Keeler, The Texas Chiropractic Association’s award designating the Chiropractor of the year, The Keeler Plaque, is Texas Chiropractic’s most prestigious award. Nominations for the Keeler Plaque should be sent to: Dr. Curtis McCubbin Secretary, Keeler Plaque Committee P. O. Box 272 Hunt, Tx 78024 All nominations will be held in strict confidence to assure that the recipient will be surprised when their name is announced. A candidate shall be: A member in good standing in the TCA Of good moral character A promoter of chiropractic advancement in at least one of the three years immediately proceeding the year in which the award is to be presented. Such advancement may be in research, public relations, school participation, promotion or support. The candidate’s main endeavor must be in the practice of chiropractic and must have promoted chiropractic throughout their career. Civic, church or community involvement, individually or within organizations or groups, and holding offices in local, state or national chiropractic organizations, chiropractic boards, and chiropractic college boards may also be considered.

The Texas Chiropractic Association represents chiropractic professionals throughout the state.

First formed in 1916, this historic association has existed for nearly 100 years and has represented the interests of Texans who desire safe and effective health care from chiropractic professionals.

TCA serves to protect chiropractic professionals, their patients, and the right f o r Te x a n s t o c h o o s e chiropractic as one of their health care options.

Click on a title article for a link to the originally published article in the Te x a s J o u r n a l o f Chiropractic, Online with further links to the original source.

ABOUT OUR COVER Notice anything new about our cover? In addition to the Bluebonnets and wildflowers found near Brenham, Texas, did you notice the NEW Texas Chiropractic Association Logo? New things are in bloom and spring is in the air!

POLICIES Annual subscription to the Texas Journal of Chiropractic is included in TCA membership dues. subscription rates for non members.

Contact the TCA for

The print-format Texas Journal of Chiropractic is published up to six times per year by the Texas Chiropractic Association under the supervision of the TCA Communications Committee. Opinions expressed are those of the contributors and do not necessarily reflect the policy of the Texas Chiropractic Association or the Texas Journal of Chiropractic. Publication of an advertisement does not imply approval or endorsement by the Texas Chiropractic Association. The association shall have the absolute right at any time to reject any advertising for any reason. For advertising rates contact the TCA Office, or check online at www.chirotexas.org. All advertising material must be in graphics ready format and submitted as a .jpg, .jpeg, .gif, .swf, or .png file type.


Texas Chiropractic Association

Texas Journal of Chiropractic Volume XXVII, Issue 2

March/April 2012

Texas Journal of Chiropractic The Official Publication of The Texas Chiropractic Association

1122 Colorado, Suite 307 Austin, TX 78701 Phone: 512 477 9292 Fax: 512 477 9296 E-mail: info@chirotexas.org www.chirotexas.org Executive Officers President: Jorge Garcia D.C. President Elect: Jack Albracht D.C. Secretary: James Welch D.C.

Inside TCA Victory in the Third Court of Appeals!

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Control the Five “Rs” of Rehab Training

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Professional Trade Associations--Who Needs Them?

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Low back pain in the United States ER! !

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HHS Announces Delay in ICD-10 Implementation

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Flu Activity on Rise but Still Low! !

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Office Manager: Amy Archer Editor: Chris Dalrymple D.C., F.I.C.C.

Board of Directors District 1 District 2 District 3 District 4 District 5 District 6 District 7 District 8 District 9 District 10 District 11 District 12

Paul Munoz D.C. Jon Blackwell D.C. Jason Clemmons D.C. Mark Bronson D.C. Dr. John Quinlan D.C. Cody Chandler D.C. Lorin Wolf D.C. Shawn Isdale D.C. Mark Roberts D.C. Shane Parker D.C. Max Vige D.C. Yvonne Landavazo D.C.

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A Hidden Threat in the Surgical Suite

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Exercise Trumps Sitting Time for Kids' Health ! !

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Antibiotics No Help for Sinusitis ! !

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TCA Supports Texas Chiropractic Network!

TBCE Adopts Final Amendments to Rule 75.1 Gross Unprofessional Conduct! ! ! !

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TBCE Adopts New Rule 71.13, Chiropractic Specialties

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TBCE Proposes Amendment to 77.2 Publicity

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TBCE Proposes Amendment to Rule 71.15, Recognized Specialties! ! ! ! ! ! ! 17 TBCE Proposes Amendment to Rule 75.2, Proper Diligence and Efficient Practice of Chiropractic ! ! ! 18 The Drug Problem! !

Copyright 2012 All Rights Reserved: Texas Chiropractic Association

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Dallas MD in Biggest Medicare Fraud in U.S. History

What it Takes to be a Servant Leader! TCA Staff

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Eat Well, Live Longer Chiropractic Indy Car!

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TCA Victory in the Third Court of Appeals TCA successfully defends scope of practice rules On April 5, 2012, the Third Court of Appeals issued a 58 page opinion in the Texas Board of Chiropractic E x a m i n e r s a n d Te x a s Chiropractic Association vs. Texas Medical Association, Texas Medical Board and State of Texas, Cause No. 03-10-673-CV. The case presented three questions: 1) Are the two TBCE rules that allow chiropractors to make certain “diagnoses” valid? 2) Can chiropractors perform MUA? 3) Can chiropractors perform needle EMG? Are the two TBCE rules that allow chiropractors to make certain “diagnoses” valid? Answer: Yes. On the two most important issues presented by TCA, the Court of Appeals upheld the validity of TBCE’s Rules 75.17(d)(1) (A) and (B) (“the scope of practice rules”).

Texas Journal of Chiropractic

“Are the two TBCE rules that allow chiropractors to make certain “diagnoses” valid?” “Answer: Yes.” “The Court found that the Board rule does not exceed the scope of practice.” The first rule, 75.17(d)(1)(A), permits chiropractors to render diagnoses “regarding the biomechanical condition of the spine and musculoskeletal system,” and listing six typical diagnostic areas as examples of what is within the scope of practice. District Court Judge Yelenosky had struck down that rule, stating that it created an unlimited authorization to diagnose any disease or condition, which, he said, exceeded chiropractors’ scope of practice. The Court of Appeals disagreed and reversed Judge Yelenosky’s decision. The Court found that the Board rule does not exceed the scope of practice because the Rule limits chiropractors to making diagnoses of the biomechanical condition of the spine and musculoskeletal system.

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The second rule, 75.17(d)(1) (B), permits chiropractors to diagnose subluxation complexes of the spine or musculoskeletal system, and lists three examples of what is within the scope of practice. T h e Te x a s M e d i c a l A s s o c i a t i o n a n d Te x a s Medical Board had challenged that rule, claiming that the rule allowed chiropractors to diagnose neurological conditions, and pathological and neuro-physiological consequences that effect the spine and musculoskeletal system. Judge Yelenosky had agreed, and struck down the rule because he found that it expanded the scope of chiropractic beyond what was allowed in the Chiropractic Act. Again, the Court of Appeals disagreed with Judge Ye l e n o s k y . T h e C o u r t acknowledged that a subluxation complex could have functional or pathological consequences www.chirotexas.org


that affect essentially every part of the body. But the Court found that the rule itself only allowed chiropractors to render a diagnosis regarding a subluxation complex of the spine or musculoskeletal system. That authority, the Court held, was consistent with the Chiropractic Act. Can chiropractors perform MUA? Answer: No. The Court of Appeals found that MUA is outside the scope of chiropractic. The Chiropractic Act bans procedures listed in the surgery section of the CPT codebook, and the Court found that MUA is in the surgery section of the CPT codebook. TCA had argued that “chiropractic MUA” is actually in the chiropracticspecific section of the CPT codebook, not the surgery section, but this argument was undermined when TBCE agreed with TMA and TMB that the surgery section covers chiropractic MUA. The Chiropractic Act also prohibits the TBCE from certifying chiropractors in MUA, and TCA and TBCE argued that this provision implies that chiropractors can perform MUA without certification. But the Court believed that prohibiting certification could have been the Legislature’s way of stopping the Board from finding that a D.C. had met www.chirotexas.org

the requirements to perform MUA. Despite the result reached by the Court, there is a silver lining to the Court’s opinion on this issue. The Court found that only procedures listed in the 2004 version of the CPT codebook are banned surgeries. That means any subsequent changes to the CPT cannot change the scope of surgery and thus the scope of chiropractic. So the AMA cannot attempt to whittle away at the scope of chiropractic by changing the CPT codebook. The damage is contained.

Because the rules allowed chiropractors to perform needle EMG with these kinds of needles, the court found that the rules were too broad and violated the statutory ban on incisions. Again, the Court made its ruling very narrowly. TBCE may be able to adopt a new rule authorizing some forms of needle EMG. The opinion acknowledges that needle EMG can be performed without using beveled-edge needles. Although the court didn't come out and say it, the opinion leaves open the possibility that a more

“Any subsequent changes to the CPT cannot change the scope of surgery and thus the scope of chiropractic.” Can chiropractors perform needle EMG? Answer: No. The Court of Appeals struck down the Board’s needle EMG rules. The court agreed that chiropractors cannot make "incisions" and that the technical meaning of an "incision" is a "cut." The court then looked to TMA's evidence, which included testimony that some needles used in needle EMG have a beveled edge designed to cut tissue. The court found that the use of these needles would be "incisive" and thus banned. 2

narrowly-crafted rule would be legally permitted, as long as chiropractors are limited to performing needle EMG with non-beveled-edge needles. CLICK HERE to read a more detailed excerpt of the court’s decision. CLICK HERE to read the complete court decision CLICK HERE TO DOWNLOAD a copy of the decision.

TCA: Working to protect chiropractic since 1916 Texas Journal of Chiropractic


Control the Five “Rs” of Rehab Training

strain on the involved tissues. Proper instruction, continued monitoring, and specific corrections are necessary factors preventing overload injuries. A Trio of Errors

by Kim D. Christensen, DC, DACRB, CCSP, CSCS The human body reacts positively to the increased stresses placed upon it. As one of the basic tenets of physical rehabilitation, this is the whole reason we command muscles to lift more weight, tendons to pull more tension, and joints to undergo more movement. In order to develop and improve our physical capabilities, we place increased, yet controlled stresses on our bodies. P a r a d o x i c a l l y h o w e v e r, increased physical stress is often the cause of symptomatic conditions and physical breakdown. What is the difference? Actually, several have been identified. Progressive overloading of responsive tissues is, in essence, the principle that underlies the benefits of exercise training. Benefits which accrue as the body’s normal recuperative processes respond and improve in function include increased strength and endurance, better flexibility, and improved coordination. Our goal is to stimulate these beneficial improvements, while avoiding any errors which might place excessive

Texas Journal of Chiropractic

There are three categories of exercise errors that indicate excessive loading of involved tissues. Most problems with exercises are associated with a “loss of form.” (1) This somewhat nebulous phrase can be defined as consisting of three problems: Postural Imbalance, Misalignment, and Movement Restriction. By paying attention to our patients as they perform their exercises, we can identify these problems early on, and make appropriate recommendations. Postural Imbalance. Look for any abnormal or imbalanced postures during exercising. Whether the patient is strengthening, stretching, or walking, hyperextensions and lateral shifts indicate an overload situation. This is easily seen during cervical training, when patients strain and push their heads forward, instead of maintaining a balanced alignment throughout their exercise. Misalignment. The more subtle deviation of misalignment during exercising relates primarily to the extremities. This can be 3

especially noticed in the feet (toe-out), ankles (excessive pronation), and knees (knockkneed). These are all indicators that additional exercising in these conditions will likely bring about a recurrence of symptoms, rather than improvement. Addressing the misalignments and asymmetries are paramount for progress, and may require custom-made stabilizing orthotics. Movement Restriction. Any limitation in range of motion during an exercise should prompt a search for the underlying cause. This may be a reasonable selfprotective response due to r e c e n t i n j u r y, o r ( m o r e commonly) an inappropriate fear response. It is also possible that the patient is placing excessive loads on sensitive tissues that are incapable of handling that amount of stress in their current state. A Quintet of Solutions Excessive loading, whether of r e s i s t a n c e , f l e x i b i l i t y, endurance, or proprioceptive exercises, is never helpful, and can be counterproductive. Five solutions all start with the letter “R.” They are: Rest, Range, Rate, Resistance, and Repetitions. (2) Rest. By increasing the rest period between exercises, or www.chirotexas.org


between sets, we allow the body to recharge and to better handle the overload. This is often the simplest of the solutions, as sufficient rest is frequently all that is needed to avoid rehab overload. Range. Controlling the range of an exercise or a stretch may be needed, especially in the initial phases of rehab. Particularly after an injury, connective tissues may be easily aggravated by forcing too much range. This is where the body can often let us know when we have gone too far, since it will give us a pain message. Initially, we should recommend that exercises be performed only within a pain-free range of motion. Rate. Slowing down the pace of an exercise and incorporating a relaxed breathing cycle will often reduce exercise stress significantly. In fact, slow and controlled exercising stimulates more neurologic control and re-training without overstressing tissues. Resistance. Whether using exercise bands, weights, or machines, careful control of the amount of resistance is important. Isotonic strengthening exercises that focus on the eccentric (negative) component have been shown to improve the healing of www.chirotexas.org

tendons and accelerate return to sports participation. (3) However, excessive resistance can quickly produce the problems in posture, alignment, and range of motion described above, resulting in a poor response to care. Repetitions. And finally, one of the easiest ways we can overload our patients is to recommend too many repetitions of too many exercises. It is far better that a few repetitions of a few exercises be done regularly and consistently, and be interspersed with sufficient rest. When we keep our eyes peeled for the three types of “loss of form,” and then carefully control the “five Rs” of rehab training, we can avoid exercise overload and ensure a smooth response to chiropractic rehabilitation training. References 1. M u l l i n e a u x M . S t r e n g t h conditioning: developing your teaching technique. Strength Cond J 2001; 23:17-19. 2. M u l l i n e a u x M , R o w e L . Manipulating training variables for safety and effectiveness. Strength Cond J 2003; 25:33-36. 3. Niesen-Vertommen Sl et al. The effect of eccentric versus concentric exercise in the management of Achilles tendinitis. Clin J Sport Med 1992; 2:109-113.

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About the Author Kim D. Christensen, DC, DACRB, C C S P, C S C S , d i r e c t s t h e Chiropractic Rehab & Wellness program at PeaceHealth Hospital in L o n g v i e w, W a s h . He has participated as team chiropractor to high school and university athletic programs, a postgraduate faculty member at numerous chiropractic colleges, past-president of the ACA Rehab Council, and a lecturer and author of many musculoskeletal rehabilitation texts. Dr. Christensen can be reached via email: kchristensen@peacehealth.org.

Professional Trade Associations-Who Needs Them? By Chris G. Dalrymple D.C., F.I.C.C.

A professional trade association is something that the majority seldom think about. Most view them as a "fraternal organization" that exists to provide "benefits" to members. But a professional trade association is much more important than that. Permit me to share some thoughts. A "profession" is d e fi n e d a s " a v o c a t i o n requiring knowledge of some department of learning or science." It is derived from the Latin word meaning "occupation one professes to be skilled in." A profession is what you do for a living that you tell people that you are "good at." Texas Journal of Chiropractic


In our society the governments regulate who may claim that they are skilled in particular occupations and, further, just what may be claimed. This is done through the licensing and regulation of those licenses. The state determines who, and how many, may participate in a profession. A "trade" is defined as "any occupation pursued as a business or livelihood." A trade may be licensed as a profession. A profession may be a trade. The word "trade" means "path, track, course of action." It came to denote "one's habitual business." Trades are likewise licensed and regulated by the state. An "association" is "an organization of people with a common purpose and having a formal structure." Wikipedia tells us that a "professional association is usually a nonprofit organization seeking to further a particular profession, the interests of individuals engaged in that profession, and the public interest." "The roles of these professional associations have been variously defined: 'A group of people in a learned occupation who are entrusted with maintaining control or oversight of the legitimate practice of the occupation;' also a body acting 'to safeguard the public interest.'" Texas Journal of Chiropractic

So the answer to the question "professional trade associations--who needs them?" is this: EVERYONE involved in a profession, or a trade, regulated by a state needs them! Why? Because the state regulatory entities are "a group of people in a learned occupation who are entrusted with maintaining control or oversight of the legitimate practice of the occupation�; and the ones charged to "safeguard the public interest." THEY make the rules to enforce the laws created by our public representatives. If there were no professional trade associations then there would be no "organization of people with a common purpose and having a formal structure" seeking to influence those who make the laws, OR those who create the rules, and thus the professions would be entirely at the whim of a small number of appointed government officials. When a large number of members of a profession join together in common purpose to make their opinions known, or to legally challenge authorities, then "THE PROFESSION" can make it's voice heard. When a small number of appointed individuals, or a small number of passionate individuals, speak on behalf of a profession the result may, or 5

may not, be the opinion of "the profession." Who needs professional trade associations? YOU do; and EVERY member of a profession, EVERY member of a trade, and EVERY member of occupations associated with that trade or profession ought to be associated with their professional trade association, otherwise they are not supporting the growth and development of their profession nor the businesses surrounding it that thrive because of it. If one is not supporting the growth and development of their profession, then one is contributing to its atrophy and demise.

Low back pain in the United States ER The Spine Journal reports that "low back pain is prevalent in the United States. At the present time, no large longitudinal study is available characterizing the incidence of this condition in the US population or identifying potential risk factors for its development.� A study was conducted to “characterize the incidence of acute low back pain requiring medical evaluation in the emergency department and establish risk factors for its development." www.chirotexas.org


"The National Electronic Injury Surveillance System was queried for all cases of low back pain presenting to emergency departments between 2004 and 2008." "An estimated 2.06 million episodes of low back pain occurred among a population at risk of over 1.48 billion person-years for an incidence rate of 1.39 per 1,000 personyears in the United States.” “Low back pain accounted for 3.15% of all emergency visits. Injuries sustained at home (65%) accounted for most patients presenting with low back pain.” “Low back pain demonstrates a bimodal distribution with peaks between 25 and 29 years of age and 95 to 99 years of age without differentiation by underlying etiology.” “When compared with females, males showed no significant differences in the rates of low back pain. However, when analyzed by 5-year age group, males aged 10 to 49 years and females aged 65 to 94 years had increased risk of low back pain than their opposite sex counterparts.” “When compared with Asian race, patients of black and white race were found to have significantly higher rates of low back pain. Older patients were found to be at a greater risk of hospital admission for low back pain." www.chirotexas.org

The study concluded that "Age, sex, and race are significant risk factors for the development of low back pain necessitating treatment in an emergency department."

to increase in the early weeks of March, the CDC is reporting. The start of the influenza season is usually marked when 10% of respiratory samples taken in cases of influenza-like illness test positive for the virus, according to Joseph Bresee, MD, of the CDC."

HHS Announces Delay in ICD-10 Implementation

"This year, that mark wasn't reached until the week ending Feb. 4; the percentage rose to 13.4% in the week ending Feb. 11, and 14.4% in the week ending Feb. 18 … It's the "latest start to the flu season in 20 years. … The peak of the flu season usually occurs in February, CDC researchers noted …. in the past 35 years the peak of the flu season has occurred four times in March and twice in April. For that reason, the agency is still urging people to get a flu shot."

The ACA reports that Health and Human Services (HHS) Secretary Kathleen G. Sebelius announced a postponement for the implementation of ICD-10. Va r i o u s h e a l t h c a r e professions expressed concerns about the challenges and administrative burdens implementation will place on providers. Marilyn Tavenner, acting CMS administrator, states that CMS will be re-examining the pace of ICD-10 implementation.The revised deadline date should be announced soon. Although the deadline is postponed, it's important to prepare for this transition.

Flu Activity on Rise but Still Low Medpagetoday.com reported that "it has been a mild flu season so far, but influenza activity has gradually started 6

"Since October 2, outpatient visits for influenza-like illness (ILI), reported by the Outpatient ILI Surveillance Network, have been between 1.1% and 2.1% of all visits, below the national baseline of 2.4%." "Since October 2, the weekly percentage of deaths attributed to pneumonia has varied from 5.9% to 7.9%, but has not exceeded the epidemic threshold of 7.9% for more than a week, the CDC reported." "The agency also found that, as of February 11, there have been just three children Texas Journal of Chiropractic


whose deaths have been linked with influenza. Last season, in contrast, there were a total of 122 influenzarelated pediatric deaths."

Medicare fraud: Dallas MD Accused in Biggest Case in U.S. History The LA Times has reported that "Federal law enforcement officials announced what they called the largest healthcare fraud case in the nation’s history, indicting a Dallas area physician for allegedly bilking Medicare for nearly $375 million in billings for nonexistent home healthcare services."

"Top Justice Department officials, working for several years to stem a rampant rise in healthcare fraud around the c o u n t r y, a l s o r e v e a l e d Tuesday that 78 home health agencies that were working w i t h t h e p h y s i c i a n , D r. J a c q u e s R o y, w i l l b e suspended from the Medicare program for up to 18 months." "FBI agents in Texas arrested Roy, of Rockwall, Texas, a physician for 28 years, and asked a federal judge in Dallas to keep him in custody until trial, citing his vast “bank accounts, a sailboat, vehicles and multiple pieces of property” as indications he may attempt to flee." "Facing life in prison and a $250,000 fine, as well as restitution of the vast sum of money he allegedly cost the federal government, Roy is to appear in court in Dallas."

Call for Nominations for Young Chiropractor of the Year Established over half a century ago, this award is for the purpose of recognizing doctors who have shown outstanding dedication and who have made long-lasting contributions to the profession and their community, and who are under 40 years of age or in active practice for fewer than 10 years at the time of the award’s receipt. Send nominations to 2011 recipient: Dr. John Quinlan D.C. 120 South Denton Tap Rd., Suite 410; Coppell, TX, 75019 Phone: 972-304-5900 Fax: 972-304-6047 drquinlan@quinlanchiropractic.com

Texas Journal of Chiropractic

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"Under the alleged fraud scheme, the doctor and his office manager in DeSoto, Texas, Teri Sivils, who was also charged, allegedly sent healthcare “recruiters” doorto-door asking residents to sign forms that contained the doctor’s electronic signature and stated that he had seen the residents professionally for medical services he never provided." "They also allegedly dispatched more 'recruiters' to a homeless shelter in Dallas, paying $50 to every street person they coaxed from a nearby parking lot and signed him up on the bogus forms." "The long-running ruse allegedly began in 2006 and over five years collected more Medicare beneficiaries than any other medical practice in the United States." Atty. Gen. Eric H. Holder Jr., in testimony ... before a House appropriations subcommittee, said …. “This represents the highest amount ever recovered in a single year.”

A Hidden Threat in the Surgical Suite The Associated Press reports that "filthy, dangerous medical implements have been showing up in hospitals and outpatient surgery centers with alarming regularity.” www.chirotexas.org


“In 2009, the Department of Veterans Affairs admitted that 10,737 veterans in Florida, Tennessee and Georgia were given endoscopies or colonoscopies between 2002 and 2009 with endoscopes that may have been improperly cleaned. Some of those patients later tested positive for HIV, hepatitis C, or hepatitis B. Several lawsuits fi l e d a g a i n s t t h e VA b y veterans are currently working their way through the courts, and attorneys expect many others to follow.” “Investigation of a 2008 hepatitis C outbreak that sickened at least six people in Las Vegas revealed that an outpatient surgery center was improperly cleaning endoscopes and reusing biopsy forceps designed for a single use. Following that outbreak, a Centers for Medicare and Medicaid Services (CMS) pilot program inspected 1500 outpatient surgery centers and cited 28 percent for infection control d e fi c i e n c i e s r e l a t e d t o equipment cleaning and sterilization." "Last summer, the Food and Drug Administration (FDA), which regulates medical devices, held a little-noticed workshop to address concerns regarding dirty devices. Over two days, manufacturers, hospital representatives, and officials from the CDC and FDA described the challenges of thoroughly cleaning complex www.chirotexas.org

but reusable medical devices between procedures." In one report researchers "ran a tiny surgical video camera inside 350 surgery-ready suction tips (a common tool surgeons use to suction blood and fluids). All of the suction tips … contained blood, bone, tissue, even rust. … After discovering the debris, the team ran the 350 suction tips through the manufacturer’s recommended cleaning and disinfection processes and reexamined them. All but seven of the suction tips still contained debris." "At the FDA workshop, experts pointed to several other reasons, including the proliferation of highly complex surgical instruments, inadequate device testing by manufacturers, and the struggle faced by poorly-paid hospital employees who clean and sterilize devices between procedures, often under pressure from nurses and surgeons who need the devices quickly for the next operation." "It is difficult to know exactly how often dirty instruments are to blame for the infections that plague hospitals, since bacteria can hide anywhere from a doctor’s unwashed hands to a nurse’s dirty scrubs. But experts say it happens far more often than generally understood."

glass, and many looked like the tools used by a butcher or an auto mechanic. Cleaning these tools was simple, and sterilization required little more than a heavy shot of steam." "The tremendous growth of minimally invasive surgeries i n t h e 1 9 9 0 s , h o w e v e r, brought flexible endoscopes that are passed through tiny incisions to see inside patients. Instruments became smaller, more specialized and complex, with moving parts, tiny holes, and long narrow channels running the length of the implements. Manufacturers turned to materials like tungsten, plastic and other polymers. Progress continues. As surgeons begin to rely on robotics, devices are becoming even more elaborate." "Intricate modern instruments revolutionized surgery, but they have proven difficult to clean. Those tiny internal channels become clogged with unseen tissue and blood. Steam sterilization melts and destroys some modern devices. Instruments made of materials like rubber may not heat all the way through, as many metals do, creating sterilization challenges."

"Decades ago, medical instruments were almost exclusively made of steel and

"Theoretically, if a device is truly impossible to clean, it should never end up on hospital shelves. The FDA, as part of its medical device clearance process, requires device manufacturers to verify that their cleaning instructions are effective. Few in the

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Texas Journal of Chiropractic


industry, however, believe the regulation works. Instead of testing their tools in the real world of hospitals, industry veterans say, manufacturers usually hire independent labs to evaluate their cleaning instructions under perfect conditions." "In hospitals, the struggle to clean and sterilize surgical implements usually takes place in the basement, in hot, humid, “central sterile processing” units where employees, some making as little as $8.50-an-hour, work in fast-paced conditions to keep equipment in rotation."

of tools and frequently pressure central sterile processing units to clean them as fast as possible in order to keep patients moving through profitable surgery suites. Since techs are the low man on the totem pole, it’s hard to push back against nurses and surgical staff." "Worst of all, central sterile techs say doctors and nurses rarely acknowledge their role in successful surgeries. Except when an important person or a doctor’s family member is on the table, that is. … The fast pace, low

only New Jersey requires techs to be certified, despite a recent push by IAHCSMM and state organizations.”

prestige and low pay leads to high staff turnover, sometimes for fast food or retail jobs."

What it Takes to be a Servant Leader

“The people who do your nails, they have to take an infection control course before they can apply for a license. Same with a dog groomer. Yet the people who deal with lifesaving equipment, they are required to have zero education.”

"Technicians are responsible for cleaning and sterilizing a vast range of instruments, from the tiniest forceps to intricate modern power tools. At the largest hospitals, as many as 40,000 devices pass through every day." "While instruments are often cleaned and sent back to surgery rapidly — perhaps too rapidly ... they also sometimes sit around for hours, or days, before they are cleaned, which allows blood and tissue to dry and harden. If a device is improperly cleaned prior to sterilization, the process can bake the blood and tissue on the instrument. With devices in rotation for years, or even decades … the number of dirty devices currently in hospital supplies is likely massive." “But hospitals across the country have a limited number

"If these secrets of central sterile processing are unknown to patients, they are equally mysterious to the doctors who use the equipment. …. Central sterile techs play a key role in making sure clean devices make it to surgery suites, yet

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D r. F a b r i z i o M a n c i n i , president of Parker University presented “Servant L e a d e r s h i p : E m p o w e r, Encourage, and Inspire” during an all-school Parker assembly. Dr. Mancini told the www.chirotexas.org


audience that the core foundation of chiropractic and Parker is service. He shared the importance of chiropractors being servant leaders. “We are asked to serve as leaders within our practices, with our patients, within our families and communities each and every day,” said Dr. Mancini. For years, Dr. Mancini has studied what it truly takes to be a servant leader. He explained key characteristics that a servant leader must encompass including the first characteristic of being an effective listener. He also advised the students to build on their listening and social skills while they’re students at Parker. “Learn to really listen close to what people are telling you,” said Dr. Mancini. “If your patients aren’t talking enough, ask them questions.” He described a servant leader as someone who also has the characteristics of having empathy and understanding. Dr. Mancini expressed the s i g n i fi c a n c e o f h a v i n g understanding for what patients are going through. In addition, being solution driven and motivated to solve problems as well as being aware and observant were other traits he believes all leaders possess.

www.chirotexas.org

Dr. Mancini also spoke about the importance of leaders living and owning their message. “When you own what you’re advising your patients it’s easy to persuade others and show others the benefits they will receive from living a healthier lifestyle,” said Dr. Mancini. “When you own it, it’s easier to share the message with others.” He told the audience that good leaders are conceptual and see the big picture. He also believes that leaders must have long-term foresight. “While you’re a student at Parker think ahead and come up with ideas that will allow you to build your practice after y o u g r a d u a t e , ” s a i d D r. Mancini. “Have the practice of your dreams in mind before you get out there and write down your ideas.”

vigorous-intensity physical activity was associated with improvements in waist circumference, systolic blood pressure, triglycerides, HDL cholesterol, and insulin in participants ages 4 to 18." "The benefits of exercise were greater, however, among those with the lowest level of sedentary time, the researchers reported." “Children should be encouraged to increase their participation in physical activity of at least moderate intensity rather than reducing their overall sedentary time, as this appears more important in relation to cardiometabolic health." "They noted, however, that reducing the amount of time young people spend in front of the TV -- a marker of sedentary time -- may still be an important goal because of TV viewing's association with other unhealthy behaviors and exposure to advertisements that may promote unhealthy diets."

Exercise Trumps Sitting Time for Kids' Health Medpagetoday.com reports that "no matter how much time children and teens sit around, exercising improves their cardiometabolic risk profile, researchers found.” “Across all levels of sedentary time, moderate-to10

Antibiotics No Help for Sinusitis Medpagetoday.com reports that "antibiotics won't chase away patients' sniffles any faster than watchful waiting, researchers found.” Texas Journal of Chiropractic


“In a randomized trial, patients with acute rhinosinusitis had no differences in symptoms or quality of life three days after starting on amoxicillin compared with patients who received a placebo instead." "It provides further evidence for what we've really suspected for a long time -that in the management of patients with acute sinusitis, antibiotics do not convey any additional benefit." It's "no surprise that [amoxicillin] doesn't help. Sinusitis is almost always viral anyway." "Antibiotics are commonly used to treat sinusitis," the medical journal reports, "even though there's limited evidence to support their use in the disease, as well as serious concern about the wider problem of antibiotic resistance." "The most current CDC guidelines recommend treating only severe rhinosinusitis cases with antibiotics, the researchers said." " T h e fi n d i n g s s u p p o r t recommendations to avoid routine antibiotic use in patients with acute rhino sinusitis."

diagnosed acute rhinosinusitis," the authors wrote.

temperature accordingly."

rises

"For all children above the age of 3 months, a fever is actually a good thing. It's a

Facts About Fevers Dynamic Chiropractic has reported that "what many of us have been told is a "lowgrade fever" is a natural body temperature for some children. Much of what parents have believed for years is just not true." "Simply put, our body's first line of defense when invaded by any microbe, virus or bacteria are cells called microphages; a strong, healthy immune system may be able to eliminate the problem with this first step alone. If these fail to contain the microbe/"bug," then the body creates other pryogens and proteins to try to assist. Once these have been created, the hypothalamus in the brain recognizes there is an invader and raises the body temperature to assist in killing it off."

"There is now a considerable body of evidence from clinical trials conducted in the primary care setting that antibiotics provide little if any benefit for patients with clinically

"This elevated temperature will generally be just a couple of degrees, but the hypothalamus determines, based on the number of pryogens and proteins, what will be necessary to eliminate the microbe/bug. If the hypothalamus creates additional biochemicals to try to protect the body, then the

Texas Journal of Chiropractic

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sign that their immune system i s f u n c t i o n i n g p r o p e r l y. Although many parents will panic when their child has a temperature above 98.6° F (37° C), and this is understandable since many health care providers have called this a "low-grade fever," the reality is that children's temperature may naturally run a little higher than what many consider the norm." "A true low-grade fever is anything between 100° F and 102.2° F (37.8° C and 39° C). This level of fever is b e n e fi c i a l ; w i t h m o s t microbes/"bugs" that a child will be exposed to, this fever will assist the body in repelling the invader." "A moderate-grade fever is typically between 102.2° F and 104.5° F (39° C and 40° C). This temperature is still considered beneficial; if a child's body has reached this temperature, it's what's needed to kill whatever www.chirotexas.org


bacteria or virus their body is attempting to fight." "A high fever is a fever greater than 104.5° F (40° C). This fever may cause the child some discomfort and result in a bit of crankiness. Generally indicative of a bacterial infection, this fever means that the body is fighting something a little more serious than the common cold. While it will not cause brain damage or any other harm to a child, it is wise to seek assistance from their medical provider." "A serious fever is one that is at or above 108° F (42° C); this fever can be harmful." "Fevers that are caused by the body's immune system are not dangerous, and the hypothalamus will control the body temperature and not allow it to get so high as to cause harm. While it can be frightening to have a child running a moderate to high fever, it is simply their body doing what it was designed to do." "The only body temperature that can actually cause brain damage, despite what many parents believe, is 108° F (42° C), and this body temperature cannot typically be achieved on its own, but requires extreme external environmental temperatures – for instance, if a child is left in a closed car in hot weather." "Since it is a very rare fever that can actually cause any www.chirotexas.org

kind of harm to a child, the best response is to let it run its course; most fevers will resolve themselves in 24 to 72 hours. Parents should be aware that fevers will naturally spike a little in the late afternoon and evening, so a slight increase in temperature during these times is not a cause for alarm. A wait-andwatch approach should be recommended, rather than turning to over-the-counter chemicals." "The American Academy of Pediatrics (AAP) does not recommend fever-reducing drugs: "Fever is not an illness, rather, it is a symptom of sickness and is usually a positive sign that the body is fighting infection." Even in cases of high temperatures, the AAP says, "Fevers generally do not need to be treated with medication unless your child is uncomfortable or has a history of febrile convulsions. The fever may be important in helping your child fight the infection." "The best response to a fever below 104.5° F (40° C) for children over the age of 3 years is lots of rest and clear fluids. Since fevers may cause the child to sweat, parents need to be aware that they will lose sodium and water, which must be replaced with proper fluids." "Parents should contact the child's health care provider right away if any of the following occur: 12

A child younger than 3 months is running any grade of fever. A child between 3 months and 3 years has a temperature above 102.2° F (39° C) and appears ill (it should be noted that even teething may cause a slight increase in temperature). A child of any age has a temperature over 104.5° F (40° C)." " A d d i t i o n a l l y, s i n c e dehydration is a potential side effect of fever, encourage parents to watch their child for the following: dry mouth, lack of urine or wet diapers for 6-8 hours (or only a small amount of really dark urine), dry skin, lethargy, irritability, fatigue, or with an older child, dizziness. These signs of dehydration may be a concern and the child should be seen by a health care professional, especially if they are unable to keep down clear fluids." "It is important to note that in children under the age of 5 years, a fever can also lead to a seizure, known as a febrile seizure. However, while this can be frightening, it will typically have no lasting effects." "A fever is a natural part of a child's immune response. When it is functioning at its absolute best, a child's body will fight off most foreign invaders so swiftly that they will have no outward effect at all. However, when necessary, a child's immune system will raise their temperature to create a hostile environment Texas Journal of Chiropractic


for that invader. It's how a properly functioning body functions."

TCA Supports Texas Chiropractic Network The TCA board of directors has voted unanimously to endorse and encourage the u s e o f t h e n e w Te x a s Chiropractic Network website. TCA officers will also be participating in the TCN in order to greatly improve communication with the doctors it represents. TCN is a state-of-the-art private social community c r e a t e d j u s t f o r Te x a s ' chiropractors. We are recommending that chiropractors now to use it to increase communication with each other and directly with their TCA representatives. TCN is a social network that makes use of a sophisticated message system, allowing you to read and respond to messages at your leisure. You can even read and reply to messages straight from your e-mail in-box. CLICK HERE TO SIGN UP FOR THE TCN. There is no charge! Why?

Texas Journal of Chiropractic

1. We are far behind other healthcare providers in this area. This powerful new tool will move us to the front of the pack. 2. There is now an urgent need for strong communication between doctors and with their association. TCN will provide the solution.

TBCE Adopts Final Amendments to Rule 75.1 Gross Unprofessional Conduct T h e Te x a s B o a r d o f Chiropractic Examiners reports that it has adopted as a final rule rule 75.1 Grossly Unprofessional Conduct. The new rule states: (a) Grossly unprofessional conduct when applied to a licensee or chiropractic, facility includes, but is not limited to the following: (1) maintaining unsanitary or unsafe equipment; (2) failing to use the word "chiropractor," "Doctor, D.C.," or "Doctor of Chiropractic, D.C." in all advertising medium, including signs and letterheads; 13

(3) engaging in sexual misconduct with a patient within the chiropractic/ patient relationship; (4) exploiting patients through the fraudulent use of chiropractic services which result or are intended to result in fi n a n c i a l g a i n f o r a licensee or a third party. The rendering of chiropractic services becomes fraudulent when the services rendered or goods or appliances sold by a chiropractor to a patient are clearly excessive to the justified needs of the patient as determined by accepted standards of the chiropractic profession; (5) submitting a claim for chiropractic services, goods or appliances to a patient or a third-party payer which contains charges for services not actually rendered or goods or appliances not actually sold; (6) failing to disclose, upon request by a patient or his or her duly authorized representative, the full amount charged for any service rendered or goods supplied. (b) Sexual misconduct as used in subsection (a)(3) of this section means: (1) sexual impropriety, which may include: www.chirotexas.org


( A ) a n y b e h a v i o r, gestures, statements, or expressions which may reasonably be interpreted as inappropriately seductive, sexually suggestive or sexually demeaning; (B) inappropriate sexual comments about and to a patient or former patient including sexual comments about an individual's body or sexual comments which demonstrate a lack of respect for the patient's privacy;

any conduct by a person or between persons that is intended to cause, is likely to cause, or may be reasonably interpreted to cause to either person stimulation of a sexual nature, such as: (A) sexual intercourse; (B) genital contact; (C) oral to genital contact; (D) genital to anal contact; (E) oral to anal contact;

(C) requesting unnecessary details of sexual history or sexual likes and dislikes from a patient;

(F) oral to oral contact;

(D) making a request to date a patient;

(I) encouraging another to masturbate in the presence of the licensee;

(E) initiating conversation regarding the sexual problems, preferences, or fantasies of the licensee; (F) kissing or fondling of a sexual nature; or (G) any other deliberate or repeated comments, gestures, or physical acts not constituting sexual intimacies but of a sexual nature; or (2) sexual intimacy, which may include engaging in www.chirotexas.org

(G) touching breasts; (H) touching genitals;

the person more than six months before the date the sexual impropriety or intimacy occurred. (d) It is not a defense under subsection (a)(3) of this section if the sexual impropriety or intimacy with the patient occurred: (1) with the consent of the patient; (2) outside professional treatment sessions; or (3) off the premises regularly used by the licensee for the professional treatment of patients. (e) Licensees must respect a patient's dignity at all times and should provide appropriate gowns and/or draping and private facilities for dressing and undressing.

(J) masturbation by the licensee when another is present; or (K) any bodily exposure of normally covered body parts. (c) It is a defense to a disciplinary action under subsection (a)(3) of this section if the patient was no longer emotionally dependent on the licensee when the sexual impropriety or intimacy began, and the licensee terminated his or her professional relationship with 14

TBCE Adopts New Rule 71.13, Chiropractic Specialties T h e Te x a s B o a r d o f Chiropractic Examiners reports that it has adopted a final amendment to Rule 71.13, Chiropractic Specialties. The newly adopted rule reads: Texas Journal of Chiropractic


(a) This rule outlines the requirements for applying to the board for recognition of a specialty to include documentation required and information reviewed by the board in determining whether a practice area is a specialty. (b) Any person or entity may submit an application to the board seeking recognition of a specialty area. For the purpose of this regulation a specialty shall consist of advanced education and/or training to be proficient in an area of practice and shall not include a technique of manipulation or treatment. (c) An application for recognition of a specialty area shall be submitted on a form provided by the board. Within the application the following information and documentation shall be submitted: (1) Name and description of the specialty certification area; (2) Conditions and/or disorders to which the specialty area is directed; (3) Proof of acceptance of the specialty area by the chiropractic profession to include safety and efficiency of the specialty area, such as articles from refereed journals, scholarly journals, treatises, textbooks used by board approved Council of Chiropractic Education (CCE) colleges of chiropractic, syllabi and/or Texas Journal of Chiropractic

curriculum materials used in education and training in the specialty area, and scholarly studies or research; (4) Education and/or training requirements including how and where education may be obtained and whether education and/or training is provided from a post graduate board-approved CCE chiropractic college; (5) A statement describing why the specialty area complies with the scope of practice as defined in ยง75.17 of this title, relating to Scope of Practice; (6) Any examination or residency required; and (7) Hours of continuing education to maintain the certification. (d) The board shall review an application for recognition of a specialty area and require documentation to determine compliance with the following factors: (1) Whether the c e r t i fi c a t i o n i s f o r a specialty area, or for a technique; (2) Whether the specialty area is within the scope of practice of chiropractic as defined in ยง75.17 of this title;

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(3) Whether the specialty area is safe for its intended purpose(s); (4) Whether there are s u f fi c i e n t s o u r c e s o f accredited core and post graduate education at board-approved CCE colleges of chiropractic; and (5) Whether recognition of a specialty area will create potential public confusion in the event the specialty area is already being commonly used and advertised by licensees. (e) The applicant shall be responsible for providing all documents required by the board and the applicant shall have the burden of demonstrating that the specialty area should be recognized by the board. (f) Upon approval of a specialty area, the board shall promulgate a regulation establishing the minimum initial and continuing education requirements, application fee, and documentation required for verification of compliance with all educational requirements. (g) Licensees receiving boardapproved specialty certification shall be entitled to use the terms, specialty, or specializing in public communications, including advertisements, letterhead, and signage. Any such specialty designate shall be preceded by the licensee's www.chirotexas.org


name, and by one of the following: (1) D.C.;

of chiropractic as described under ยง75.17 of this title (relating to Scope of Practice)[, relating to scope of practice].

name of each person called. Such scripts and logs shall be maintained for a minimum of two years.

(c) A licensee or [registered] facility engaging in, or authorizing another to engage in telemarketing of prospective patients shall not misrepresent to the person called any association with an insurance company or another doctor of chiropractic or another chiropractic group or facility.

(d) Licensees or [registered] facilities that intend to include a testimonial as part of any form of public communication shall maintain a signed statement from that person or group to support any statements that may be used in any public communication for a minimum of two years from publication of the testimonial.

(2) Chiropractor; or (3) Doctor of Chiropractic.

TBCE Proposes Amendment to 77.2 Publicity T h e Te x a s B o a r d o f Chiropractic Examiners REPORTS HERE that it has proposed amendments to rule 77.2 Publicity. The proposed new rule states [bold is newly added; light color and bracketed is deleted text]: (a) A registered facility or licensee shall not, on behalf of himself, his partner, associate, or any other licensee or facility affiliated with him, use or participate in the use of any form of public communication which contains a false, fraudulent, misleading, deceptive, or unfair statement of claim, or which has the tendency or capacity to mislead or deceive the general public, as defined in ยง77.5 of this title (relating to Misleading Claims). (b) In any form of public communication, a licensee or [registered] facility shall not describe services that are inconsistent with the practice www.chirotexas.org

(1) A licensee, [registered] facility, or their agent, engaging in telemarketing shall not promise successful chiropractic treatment of injuries or make any other communication which would be prohibited under subsection (a) of this section. (2) A licensee, [registered] facility, or their agent, engaging in telemarketing are required, at the start of each call, to inform the person called who they are (caller's name) and who they represent (clinic/ doctor). (3) A licensee or [registered] facility engaging in telemarketing, either directly or through an agent, shall keep a copy of each script used for calling and a log of all calls made that shall include the date, telephone number, and the 16

(e) Licensees or [registered] facilities shall clearly differentiate a chiropractic office, clinic, or facility from another business or enterprise in any form of public communication. (f) Licensees shall identify themselves as either "doctor of chiropractic," "DC," or "chiropractor" in all forms of public communication. If each licensee that practices in a [registered] facility has identified themselves as required in this subsection [above], then the facility name need not include "chiropractic" or similar language. (g) In any form of public communication using the phrase "Board Certified" or similar terminology associated with any credentials, a licensee must identify the board certifying said credentials.

Texas Journal of Chiropractic


(h) In any form of public communication, if a licensee or facility makes a claim based on one or more research studies, the licensee or facility shall clearly identify the relevant research study or studies and make copies of such research studies available to the board or the public upon request. (i) In any form of public communication, a licensee or facility shall not advertise any service as "free" unless the public communication clearly and specifically states: (1)all the component services which will or might be performed at the time of, or as part of, the service; (2) as to each such component service, whether that service will be free or, if not, the exact amount which will be charged for it; and

telemarketing done by or on behalf of a licensee or facility, including activities conducted by employees, students being mentored by the licensee, or other agents.

TBCE Proposes Amendment to Rule 71.15, Recognized Specialties T h e Te x a s B o a r d o f Chiropractic Examiners R E P O RT S H E R E i n t h e Texas Register a proposed amendment to Rule 71.15, Recognized Specialties. Deletions are in [brackets and a light color] and additions are in bold: (a) The following chiropractic specialties have been approved by the board:

(3) if a component service is an evaluation, whether the report of findings will be free or, if not, the exact amount which will be charged for the report of findings.

(i) Diplomate, Academy of Chiropractic Orthopedists;

(4) The effective date of this subsection is June 1, 2012.

(ii) Diplomate, American Board of Chiropractic Orthopedists; or

(j) This section and ยง77.5 of this title apply to all a d v e r t i s i n g , communications, or

(iii) Fellow, Academy of Chiropractic Orthopedists.

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(1) Chiropractic Orthopedic. (A) Requirements:

(B) Continuing e d u c a t i o n requirements: Thirty-six hours of continuing education during the three years prior to recredentialing approved by the Academy of C h i r o p r a c t i c Orthopedists. (2) Chiropractic Radiology. (A) Requirements: Diplomate, American Chiropractic Board of Radiology. (B) Continuing e d u c a t i o n requirements: (i) Sixty continuing education credits over a period of five years in the field of diagnostic imaging; (ii) Successfully completing an American Chiropractic Board of Radiology certification examination; or (iii) Another manner recognized and approved by the American Chiropractic Board of Radiology. (3) Acupuncture. (A) Requirements: (i) Diplomate in Acupuncture from a recognized CCE-accredited institution/post-graduate entity; or (ii) Three hundred hours of instruction conducted www.chirotexas.org


under the auspices of and taught by the post-graduate faculty of a CCE-accredited institution. (B) Continuing e d u c a t i o n requirements: Three hours of continuing education in clean needle technique acupuncture every fi v e y e a r s . T h e s e hours may be counted as part of the total continuing education hours required each year by the board. The hours must be obtained from board-approved continuing education courses. (b) Licensees must submit proof of eligibility to the board prior to recognition as a chiropractic specialist in any of the fields listed in subsection (a) of this section. Licensees are prohibited from referring to themselves as specialists without approval from the board.

TBCE Proposes Amendment to Rule 75.2, Proper Diligence and Efficient Practice of Chiropractic www.chirotexas.org

T h e Te x a s B o a r d o f Chiropractic Examiners reports a proposed amendment to Rule 75.2, Proper Diligence and Efficient Practice of Chiropractic. Deletions are in a [light color and brackets] and additions in bold: (a) A lack of proper diligence in the practice of chiropractic o r t h e g r o s s i n e f fi c i e n t practice of chiropractic when applied to a licensee or chiropractic facility includes but is not limited to the following: (1) failing to conform to the generally accepted standards of care within the chiropractic p r o f e s s i o n i n Te x a s [minimal acceptable standards of practice of chiropractic], regardless of whether or not actual injury to any person was sustained, including, but not limited to: (A) - (C) (No change.) (D) causing, permitting, or allowing physical injury to a patient or impairment of the dignity or the safety of a patient [or]; (E) abandoning patients without reasonable cause and without giving a patient adequate notice and the opportunity to obtain the services of another chiropractor 18

and without providing for the orderly transfer of a patient's records; [.] (F) failing to timely refer a patient to an appropriate health care provider when the licensee determines or should have determined that the patient may suffer from a condition: (i) that requires a diagnosis outside the chiropractic scope of practice as a u t h o r i z e d b y Te x a s Occupations Code ยง201.002 or ยง75.17 of this title (relating to Scope of Practice); or (ii) that requires treatment outside the chiropractic scope of practice as a u t h o r i z e d b y Te x a s Occupations Code ยง201.002 or ยง75.17 of this title; or (G) failing to timely refer a patient to an appropriate health care provider when the licensee determines or should have reasonably determined that the patient suffers from a condition that is within the chiropractic scope of practice, but requires a diagnosis or treatment that exceeds the licensee's education, training or experience. Texas Journal of Chiropractic


(2) (No change.) (b) (No change.)

The Drug Problem M e d p a g e to d a y.c o m REPORTS HERE that "prescriptions for narcotic painkillers soared so much over the last decade that by 2010 enough were being dispensed to medicate every adult in the U.S. around-theclock for a month." T h e Te x a s J o u r n a l o f Chiropractic, Online highlighted the severity of this problem in a four part series. What has been reported is that "Fueling that surge was a network of pain organizations, doctors and researchers that pushed for expanded use of the drugs while taking in millions of dollars from the very companies that made them." "Without rigorous scientific evidence to prove that their benefits out weigh potential harm, drugs like OxyContin and Vicodin increasingly have been used to treat a wide array of chronic pain syndromes including low back pain and fibromyalgia." "Current practices reflect a gradual shift from the use of these drugs to treat short-term acute pain such as postsurgical pain, as well as Texas Journal of Chiropractic

severe pain associated with metastatic cancer or end-oflife pain -- uses that were based on solid evidence that such use was safe and effective." "But the benefit seen for those conditions was extended to treatment of chronic pain syndromes, an extrapolation that had no evidence to back it up." "Led by OxyContin, sales of prescriptions of opioid drugs totaled $8.4 billion in 2011, up from $5.8 billion in 2006, according to data supplied by IMS Health, a drug market research firm." "We've never really exposed so many people to so much drug for so long. We don't really know what the longterm results are." "Several of the pain industry's core beliefs about chronic pain and opioids are not supported by good science and contributed to the growing use of the drugs ‌. Among the misconceptions: The risk of addiction is low in patients who obtain their narcotic painkillers legitimately; There is no maximum dose of the drugs that can't be safely prescribed; People who seek more frequent prescriptions or higher doses of the drugs aren't addicts, they are "pseudoaddicts" who just need more pain relief and more opioids." "Underlying those fallacies, critics say, is an even larger 19

one: That the use of narcotic painkillers to treat non-cancer pain lasting many months or years is supported by rigorous science." "Even doctors who have financial relationships with companies that make narcotic painkillers concede that the practice of pain medicine got ahead of the science." "Lynn Webster, MD, a Utah pain specialist who has worked as a consultant and adviser to most of the companies in the opioid analgesic market, said the pain community got some of it wrong. 'We overshot our mark, all well-intended, I believe,' Webster, an officer of the American Academy of Pain Medicine, said in an interview." "I don't think industry was trying to harm anyone. I think industry was trying to fill a need that we as physicians saw." "Others say that Webster is too forgiving in his analysis: they claim that the pharmaceutical industry chose profits over patient safety." "This is an out of control epidemic, not caused by a virus or a bacteria. ‌ This epidemic has been caused by a brilliant marketing campaign that dramatically changed the way physicians treat pain." "The pharmaceutical industry's alliance with pain www.chirotexas.org


groups is part of familiar playbook. It has occurred with other organizations, though those financial relationships aren't always fully disclosed …. They (drug companies) expect a certain return for their money and the sad thing is, they often get it." "Consider the American Pain Foundation, which has substantial financial ties to companies that make narcotic painkillers: a patient guide available on its web site it claims there is no maximum dose for opioids as long as they are not combined with other drugs such as acetaminophen. The dose of any painkiller, the Foundation claims, can be gradually increased over time." "The 'no ceiling' dose statement appears in the Pain Foundation's 'guide for people living in pain,' a publication that received funding from three drug companies. Two of the companies, Purdue Pharma and Cephalon, were the subject of U.S. Justice Department investigations involving their opioid products.' "In 2007, Purdue was accused of misleading doctors by claiming, with no proof, that its narcotic painkiller OxyContin was less addictive, less likely to cause withdrawal and less subject to abuse than other pain medications." "At the time, scores of deaths and an even greater number of addictions were attributed www.chirotexas.org

to OxyContin. The company and three of its executives pleaded guilty to various charges. A court imposed fines and restitution payments totaling $635 million."

Last year, the American Academy of Pain Medicine "received $1.3 million from the p h a r m a c e u t i c a l i n d u s t r y, including unrestricted grants…."

"In 2008, Cephalon settled an investigation of off-label marketing of three of its drugs, including Actiq, a powerful painkilling product manufactured as a lollipop with the drug fentanyl. The drug was approved for use only by cancer patients who

"In addition, the AAPM's "corporate relations council" allows companies that pay up to $25,000 each to gain access to physician leaders associated with the academy. Last year, that program took in $170,000." "Corporate relations council members who pay another $60,000 also can have their educational programs included as satellite dinner symposia at the academy's annual meeting in Palm Springs …. An academy brochure describes the meeting as an 'exclusive venue' for presenting continuing medical education material for doctors."

no longer were getting pain relief from morphine based drugs. Cephalon allegedly promoted the drug for noncancer patients with conditions ranging from migraines to injuries. It also promoted Actiq for use in patients who were not opioidtolerant and for whom it could have been life-threatening. Cephalon agreed to pay a $425 million penalty."

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"The American Pain Society, which funded the 1996 consensus statement on opioids and chronic pain, received more than $1.6 million in financial support from opioid companies in the last two years, more than 20% of its revenue…." "Closely tied to the addiction issue is a term -pseudoaddiction -- that has been widely used in the field of pain medicine. When patients seek more frequent prescriptions or higher doses of opioids, it often is a sign of addictive behavior. But the pseudoaddiction approach -Texas Journal of Chiropractic


essentially taking them at their word -- argues they aren't addicts, they just need more pain relief. Even doctors who have financial relationships with opioid makers concede that term is not backed up by good science." "But without adequate evidence, over the years it became an established belief in the world of chronic, non cancer pain. It can be found throughout the pain literature, ranging from American Pain Foundation documents to documents issued by the Federation of State Medical Boards, the national group representing state medical boards. The FSMB includes

Texas Journal of Chiropractic

pseudoaddition in its , model policy for the use of controlled substances in treating pain." "But even pain specialists such as Russell Portenoy, MD, who has had extensive fi n a n c i a l t i e s t o o p i o i d companies, now acknowledge that the concept of pseudoaddiction in chronic pain was not supported by evidence. 'The term has taken on a bit of a life of its own.' " Opioids in Texas Workers Compensation The Insurance Council of Te x a s r e p o r t s i n t h e i r February 21 issue of the Te x a s Workers'

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Compensation Update in an article entitled "Prescription Drug Abuse Panel Discussion Featured at TAB Annual Conference Texas Association of Business Coalition to Target Drug Abuse in Workers’ Compensation" by Albert Betts, J.D., that "Over the last several months, various workers compensation stakeholders have had ongoing discussions with the Division of Workers’ Compensation about growing concerns over overutilization and misuse of prescription drugs." " L a s t y e a r , t h e Te x a s Association of Business (TAB) organized a coalition of

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workers’ compensation insurer representatives, medical professionals, pharmacy representatives, health care representatives, and other interested stakeholders," the article reports, "to discuss and find solutions to the growing problem of prescription drug abuse in group health and workers’ compensation. The group is known as the Texas Alliance for Responsible Prescription Drug Use …." According to the AustinAmerican Statesman, Sen. To m m y W i l l i a m s ( R Woodlands) is reported to have said that "prescription drug abuse is an epidemic in Te x a s a n d t h e n a t i o n . " According to this article the newspaper reported that "Sen.Williams said during the course of the TAB panel discussion that there were 188 overdose deaths attributed to prescription drugs in Harris County alone." The article further notes that "a pain medicine physician … said the problem of prescription drug abuse is widespread. ... 7 million Americans over age 12 abused prescription drugs for non-medical purposes in 2009 and that Americans used 99 percent of the Hydrocodone and 80 percent of the Oxycodone consumed in the world." "Various studies and recent reports support [that] over utilization of drugs and inappropriate pharmaceutical www.chirotexas.org

services can lead to very serious adverse health events for injured workers. According to the US Food and Drug Administration, the most serious adverse health outcomes arising out of the overutilization of narcotics are respiratory depression, central nervous system depression, addiction and death." "Data from the Centers for Disease Control and Prevention (CDC), the article states, "indicate that accidental drug overdose is the number one injury related cause of death among adults aged 35-54 and is number two for young adults aged 15-34. In Texas, the number of accidental overdose deaths has increased 250% from 1999 to 2007 with 790 accidental drug deaths in 1999 and 1,987 accidental drug deaths in 2007. In Houston, 50 percent of all accidental overdose deaths from 2005 to 2009 were associated with prescription opioid drugs such as Oxycodone and Hydrocodone. According to Workers’ Compensation Research Insitute, Hydrocodone is the most commonly prescribed drug for injured workers nation-wide." The article also reports that the "Drug Enforcement Administration’s publication Prescription Drug Abuse- A DEA Focus (November 2008) reports that nearly 7 million Americans abuse prescription medication, a number greater than those abusing cocaine, 22

heroin, hallucinogens, Ecstacy and inhalants combined." In the same issue The Insurance Council of Texas reports further on the drug problem facing America. In an article entitled "CDC Article Discusses Prescription Drug Abuse and Offers Prevention Strategies", it is reported that "on January 13, 2012, the Centers for Disease Control and Prevention (CDC) published an article that discusses prescription drug abuse as an epidemic in the United States and offers possible abuse prevention strategies. The article also discussed the national response to the national prescription drug abuse epidemic." "The CDC reported that in 2007, approximately 27,000 unintentional drug overdose deaths occurred in the United States, one death every 19 minutes. The CDC noted that prescription drug abuse is the fastest growing drug problem in the United States." "The CDC also reported the following: The increase in unintentional drug overdose death rates in recent years has been driven by increased use of a class of prescription drugs called opioid analgesics. Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined. In addition, for every unintentional overdose Texas Journal of Chiropractic


death related to an opioid analgesic, nine persons are admitted for substance abuse treatment, 35 visit emergency departments, 161 report drug abuse or dependence, and 461 report nonmedical uses of opioid analgesics."

against doctor shopping, but they are not enforced uniformly. In contrast, only a few states have laws regulating for-profit clinics that distribute controlled prescription drugs with minimal medical evaluation. Laws against such "pill mills" as well as laws that require physical examinations before prescribing might help reduce the diversion of these drugs for nonmedical use."

function, even though their opioid dose rose significantly over the year."

The article reports that the CDC offers as one strategy: "improving legislation and enforcement of existing laws. Most states now have laws

Another strategy offered by the CDC "is to improve medical practice in prescribing opioids. Care for patients with complex chronic pain problems is challenging, and many prescribers receive little education on this topic. As a result, prescribers too often start patients on opioids and expect unreasonable benefits from the treatment. In a prospective, population-based study of injured workers with compensable low back pain, 38% of the workers received an opioid early in their care, most at the first doctor visit. Among the 6% who went on to receive opioids for chronic pain for 1 year, most did not report clinically meaningful improvement in pain and

Administration's plan for addressing prescription drug abuse, Epidemic: Responding to America's Prescription Drug Abuse Crisis, which was r e l e a s e d i n A p r i l 2 0 11 , includes four components: education, tracking and monitoring, proper medication disposal, and enforcement. The majority of health-care providers receives little or no education regarding addiction and may be at risk for prescribing an addictive medication without fully appreciating the potential risks. Therefore, the first component of the plan calls for mandatory prescriber education. This would require prescribers to be trained on appropriate prescribing of

Texas Journal of Chiropractic

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"The CDC noted that the two main populations in the United States at risk for prescription drug overdose are the approximately 9 million persons who report long-term medical use of opioids, and the roughly 5 million persons who report non-medical use (i.e., use without a prescription or medical need), in the past month. The CDC said in an attempt to treat patient pain better, practitioners have greatly increased their rate of opioid prescribing over the past decade." "The article reported that drug distribution through the pharmaceutical supply chain was the equivalent of 96 mg of morphine per person in 1997 and approximately 700 mg per person in 2007, an increase of greater than 600%. That 700 mg of morphine per person is enough for everyone in the United States to take a typical 5 mg dose of Vicodin (hydrocodone and acetaminophen) every 4 hours for 3 weeks."

"At the national level, the W h i t e H o u s e O f fi c e o f National Drug Control Policy establishes policies, priorities, and objectives for the nation's drug control program to reduce illicit drug use, manufacturing, and trafficking; drug-related crime and violence; and drug-related health consequences. ‌. The

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opioids before obtaining their controlled substance registration from the Drug Enforcement Administration (DEA)." The second component of the plan calls for prescription drug monitoring programs to be operational in all states. "Texas has a prescription drug monitoring program and is in the midst of developing an online prescription drug data base that will allow for more effective tracking of prescriptions by doctors and pharmacies," the article reports. The "CDC said the third component, proper medication disposal, is essential because the public lacks a safe, convenient, and environmentally responsible way to dispose of medications that are no longer needed. DEA is drafting rules to provide easier access to drug disposal. In support of medication disposal efforts, DEA held National Prescription Drug Take-Back Events in 2010 and 2011. During the first two such events, approximately 309 tons of drugs were collected at over 5,000 sites across the country." A fourth component calls on law enforcement agencies to help decrease prescription drug diversion and abuse. "Initial steps have been taken by Texas law makers and public policy makers to address prescription drug abuse. [legislation] during the www.chirotexas.org

2009 legislative session that requires pain management clinics to register with the Texas Medical Board in order to control pill mill operations …. has resulted in several pill mills be shut down and arrests associated with the operation of pill mills." "During the 2011 legislative session [additional legislation] makes it a criminal offense to obtain or attempt to obtain from a practitioner a controlled substance or a prescription for a controlled substance by misrepresentation, fraud, forgery, deception, subterfuge, or concealment of a material fact. SB 158 created criminal penalties for patients who visit multiple practitioners and do not disclose that they are already receiving controlled substances. The legislation also provided that defendants in pill mill cases could be charged under the Texas Penal Code’s criminal organization statutes. Senate Bill 158 amended the Texas Penal Code to expand the conditions that constitute the offense of engaging in organized criminal activity to include causing the unlawful delivery, dispensation, or distribution of a controlled substance or dangerous drug in violation of the Medical Practice Act." This article further stated that "Steve Nichols, manager of workers’ compensation services at ICT, said that there is currently no effective tool to combat prescription drug 23

abuse in the Texas workers’ compensation system. 'The lack of a rule that provides physicians and insurers with an effective tool to address prescription drug abuse and inappropriate pharmaceutical care for injured workers, including claims in which the injured employee is addicted to prescription drugs, is very concerning.' He noted that the commissioner of workers’ compensation has the authority to adopt such a rule." Further highlighting the drug problem, the Insurance Council of Texas cites the CDC and goes on to report that "for every 1 overdose death from prescription painkillers there are… • 10 treatment admissions for abuse • 32 emergency department visits for misuse or abuse • 130 people who abuse or are dependent • 825 people who take prescription painkillers for nonmedical use The Insurance Council of Texas in an article entitled "Prescription Drug Abuse: A Growing National Problem" by Stuart D. Colburn, when describing the drug problem grabs the attention by stating "We are killing our children. And we are killing their parents. When we are not successful killing our citizens, we destroy their lives and the lives of their families. The Texas Journal of Chiropractic


weapon is legal: prescription drugs."

every hour from prescription drug abuse."

He goes on to state that "hyperbole aside, no one intends such damage on our citizens. America’s prescription drug abuse (PDA) problem is not nearly as well known as our War on Drugs. No war has been declared and yet American lives are being lost."

"Prescription drug abuse is also regional, the article cites. "The federal government identified three primary hubs: southern California, southern Florida, and Harris County (Houston area), Texas. In fact, one out of six Houston-area deaths is attributed to prescription drugs. In 2010, 734 million hydrocodone pills were prescribed in Houston – enough for every man, woman, and child to consume 30 doses."

He cites some statistics highlighting the drug problem: American citizens make up 4% of the world’s population. Yet, we consume 66% of the world’s legal drugs, 99% of hydrocodone, 80% of opiates, 71% of oxycodone. An estimated 7 million Americans abuse prescription drugs: more than the number of Americans abusing cocaine, heroin, hallucinogens, e c s t a s y, a n d i n h a l a n t s combined." He further notes that "the Center for Disease Control estimated 11,500 people die a year from opiates, twice as many as cocaine and five times as many as heroin. Deaths have quadrupled over the last decade." "We are fighting the wrong war," the author states. "In 1991, doctors wrote 40 million prescriptions for opioids. In 2007, the number of prescriptions rose to 180 million. Hospital admissions increased a staggering 400% from 1998 to 2008 with a 200% increase in the number of deaths. Two Americans die Texas Journal of Chiropractic

"Nationally, the number of deaths from prescription drug abuse surpassed the number of deaths caused by alcohol a n d fi r e a r m s . R e c e n t l y, prescription drug abuse deaths exceeded the number of deaths caused by motor vehicle accidents in such states as Ohio." "In Michigan, prescription drug overdose is the second leading cause of unintentional deaths. Perhaps more troubling is that 25% of those seeking medical care were younger than age 25. "Prescription drug abuse also strikes our military forces. In 2009, our fighting forces were prescribed four times the number of pain medications they were prescribed 2001. In fact, 25% of soldiers admitted abusing prescription drugs in the last twelve months." "Although the federal government has not declared 25

war on prescription drugs, the White House did announce a policy on April 21, 2011, calling the prescription drug epidemic “our Nation’s fastest drug problem.” The article goes on to cite some reasons why the prescription drug abuse problem is rampant: "Prescription drugs are qualitatively and quantitatively different than illegal drugs. First, abusers of prescription drugs have more access to scheduled narcotics than illegal drugs. Prescription drugs are more plentiful than their illegal counterparts. Prescription drugs are not prohibited, although they are controlled and regulated by the federal government. Manufacturers can legally make - and citizens can legally take - drugs prescribed by a doctor. There is less social stigma attached to the abuse of prescription drugs. In comparison, illegal drugs are in limited supply." "Second, abusers have greater access to not only drugs but also higher quality drugs. Large companies manufacture prescription drugs in a clean and safe facility with consistent dose and strength monitored by governmental agencies. Prescription drugs are taken orally with no risk of HIV and hepatitis B or C. The quality of illegal drugs such as cocaine or heroin is circumspect with no enforcement or regulatory safeguards. Illegal drug makers can dilute their www.chirotexas.org


product to expand profits without threat of regulatory sanctions or lawsuits. Deaths occur due to impurities." The article notes that "the public’s appetite for prescription drugs leads to a lucrative secondary market. …. One study revealed 85% of respondents received drugs from someone who had a prescription. Young adults are generally the buyers and sellers in the secondary market. Kids steal from their parents’ medicine cabinets to feed their own habit or sell to others. The easy access to prescription drugs provides an adequate supply chain keeping the purchase price relatively low for other kids to enter the market. Peer pressure and addiction creates the demand. PDA moves from outcasts to the “in” kids. Soon, it is accepted and “cool” to get high with prescription drugs. Kids throw “pharm parties” where partygoers swallow handfuls of pills often not knowing what they are taking and ignorant of drug interactions. Alcohol is often the chaser. These actions can result in dangerous self-destructive behavior, injury, and death." As a stakeholder in the battle against prescription drug abuse this article states "physicians are held in high regard and command significant salaries. Like others, doctors can often be influenced by relationships and business opportunities. For example, one study of www.chirotexas.org

physicians found the following: 94% had a relationship with pharmaceutical companies; 83% receive food or drinks in the workplace from pharmaceutical companies; 78% receive drug samples; 35% receive reimbursement to attend meetings including continuing medical education, usually at plush resorts; and 28% receive payment for consulting, speaking, or enrolling patients in clinical trials."

The article further states that "physicians are both healers and entrepreneurs. Many in the profession view themselves as more than a provider of medical services to their patients but rather as business professionals. Prescription drugs are one 26

profit center. And like any good capitalists, many doctors continually look to expand their profit centers. One company marketed on LinkedIn how doctor’s offices could expand their profit margin by dispensing drugs. Physician dispensing is a hot topic across the nation. Studies show that physician dispensing increases the number of prescriptions and the cost of those prescriptions in the states that allow it. For example, payers reimburse doctors 148% more for ibuprofen in Florida and 464% more for Soma. Louisiana doctors were reimbursed 81% more than a retail pharmacy for ibuprofen and “only” 268% for soma." The article goes on to cite that "an April 2011 study by California Workers’ Compensation Institute noted that 80% of the drugs and costs in the California workers’ compensation system are prescribed by 20% of the doctors. The study focused on a breakdown of the top 10% of doctors who prescribe opiod drugs to injured workers. For example, the top 10% of physicians prescribed 79% of all Schedule II opioid prescriptions and 87% of opioid morphine equivalents. Worse, the top 1% of California physicians are responsible for a whopping 33% of all Schedule II opiod prescriptions and 41% of all Schedule II opiod morphine equivalents." Texas Journal of Chiropractic


Reporting on the business of some medical providers in supplying pain medications the article notes that "some of these providers and businesses have come to be known as pill mills. … The Texas legislature heard horror stories of pill mills popping up in strip centers around town with long lines and accepting little or no insurance. The “Houston Cocktail” was a prescription for three drugs that should never be prescribed together: hydrocodone, valium, and xanex. From January 2009 to March 2010, one Houston doctor wrote more than 43,000 prescriptions for the Houston Cocktail. In 2009, 70% of the 144,000 prescriptions of the Houston Cocktail were in fact from Houston. ...After the pill mill bill became law, there was a 45% drop in scheduled narcotics prescribed in Houston compared with the same time the year before."

o f p r e s c r i p t i o n b e n e fi t managers (PBM) has developed to combat utilization and costs of prescription drugs. Each payer is developing internal procedures to identify potential drug abuse or diversion. But each state has different laws and attitudes towards prescription drug abuse complicating their efforts."

"Prescription drug costs are rising faster than inflation and the medical CPI (medical i n fl a t i o n ) . P a y e r s a r e implementing strategies to combat the high cost and higher utilization of scheduled narcotics. A cottage industry

The White House Office of National Drug Control Policy has stated that a crucial first step in tackling the problem of prescription drug abuse is to educate parents, youth, and patients about the dangers of abusing prescription drugs, while requiring prescribers to receive education on the appropriate and safe use, and proper storage and disposal of prescription drugs. There is also a need to require all physicians to complete continuing education courses in prescribing narcotics and controlled drugs as a condition of licensure renewal. Several states are actually considering legislation to enhance physician training that focuses on the prescribing of narcotic drugs and controlled substances.

Texas Journal of Chiropractic

27

"The Coalition Against Insurance Fraud has reported that prescription drug abuse costs $72.5 billion per year, the article cites." In 2006, "almost one half of Aetna’s member fraud investigations involved prescription drug benefits."

Such effort should be undertaken in all states, the article notes." Says this article "the public has an unreasonable view of the knowledge base of healthcare providers. Although every doctor graduated from medical school, knowledge itself comes from specialized training. Scheduled narcotics should only be prescribed by doctors with the requisite training and experience. Those doctors granted the additional license to prescribe scheduled narcotics would be subject to additional regulation." The Insurance Council of Texas in an article entitled "The Opiod Epidemic In Workers’ Compensation" by Joseph Paduda, reports that "Employers and insurers will spend $1.4 billion on narcotics this year with the vast majority of those dollars paying for opioids such as OxyContin® Percoset®, Actiq®, and Fentanyl, drugs that are not indicated for most workers comp injuries." "There’s actually very little credible evidence that longterm opioid use is appropriate treatment for work comp injuries. These are drugs that were primarily developed and approved by the FDA for treating end-stage cancer pain. There's ample evidence that long-term opioid use leads to longer claim duration, long-term disability, higher costs, and higher medical www.chirotexas.org


expense. And, that's on top of the damage it does to relationships, families and society," the article reports. "The research indicates that few prescribing physicians – about one in twenty - are complying with best practices, namely assessing the patient’s initial and subsequent functionality and pain level and risk of depression, requiring patients complete and sign an Opioid Agreement, and ordering random urine drug tests to assess compliance and potential use of street and other drugs." "Opioids are synthetic versions of opium-derived drugs originally developed for treating patients with endstage cancer. Remarkably effective at reducing pain in many instances, many were meant to only last a few hours to deal with “break-through” pain. In the long term, they can provide relief from chronic pain when used appropriately within guidelines." "In the late 1990s, at least 20 states passed new laws, regulations or policies moving from the near prohibition of opioids to using them without dosing guidance. The laws were based on weak science, which in turn, was based on experience with cancer pain. Now, those same drugs are widely prescribed for musculoskeletal injuries, where their usefulness is highly questionable." www.chirotexas.org

"Research also showed the average claim costs of workers receiving seven or more opioid prescriptions for back problems without spinal cord involvement were three times more expensive than those of workers who received zero or one opioid prescription. These workers were 2.7 times more likely to be off work and had 4.7 times as many days off work. These findings suggest that greater use of opioid pain medication is associated with adverse outcomes – in addition to the high cost of the medication itself (Swedlow et al CWCI Special Report 2008)." "Some states are waking up after a long slumber and others remain in dangerous denial," the article reports "as their percent of work comp dollars spent on opioids explodes. Based on WCRI and other research, California, Pennsylvania, Louisiana, and N e w Yo r k h a v e s h o w n narcotic utilization significantly higher than the other states, with New York occupying the top spot in WCRI’s analysis. Massachusetts had by far the largest percentage of Schedule II drugs (those deemed most susceptible to abuse) used as pain medications. Again New York and Louisiana had high percentages of claimants using narcotics for an extended time." "While the use of narcotics in Texas is not as prevalent or costly as it is in those top four states, WCRI data indicates 28

the Lone Star State is well above the median in almost all utilization categories: volume of narcotics prescribed; number of narcotic scripts per claim; number of pills per script;percentage of claimants prescribed narcotics. Those data points have to be balanced against the potency of drugs prescribed by Texas’ physicians. … despite the lower potency of narcotics prescribed in Texas, the greater volume of claimants prescribed these drugs, longer duration of care, higher volume of scripts and pills per scripts combined to give Te x a s c l a i m a n t s m o r e morphine equivalents than the median WCRI state." "The inherent, but oftenignored consequence of overuse of opioids is a dramatic increase in risk of addiction and dependency. Sadly, many insurers don’t want to screen for addiction because they don’t want to “own” that addiction. The harsh reality of addiction liability is that a very high proportion of claimants who have been on opioids for more than 90 days are at high risk for addiction. Moreover, the payer already owns the addiction, they are just choosing to treat that addiction with the drug of choice rather than employ an intelligent, evidence-based approach to resolving the problem. The price tag for ongoing opioids usage runs $1,000 to $12,000 per month, plus associated drug costs for Texas Journal of Chiropractic


treating side effects, extended disability duration and settlement expense." In a related article in the same issue an article titled "Opioid Treatment Best Practices: Addressing Prescription Drug Abuse" by Mark Pew, reports that "there can be no denying that the U.S. has a problem with prescription drugs … There is no shortage of statistics that define the problem in detail (SAMHSA reports that pain reliever abuse went from 6.8% in 1998 to 26.5% in 2008, the CDC reports that opioids were involved in 73.8% (14,800) of prescription drug overdoses in 2009, NCCI’s 2011 report shows OxyContin is the #1 prescribed drug while H y d r o c o d o n e / Acetamninophen is #3 in workers’ compensation)." "There almost seems to be an American cultural expectation," the article notes, "that pain should be minimized, if not eradicated, by any means necessary." A variety of reputable sources have documented of clinical best practices documented by a variety of reputable sources for how to properly prescribe and manage prescription drugs for chronic pain. …. Texas selected the ODG treat guidelines as the standard of care for treatment provided on/after May 1, 2007. As you read through the various guidelines regarding the use of prescription drugs for managing chronic pain, one Texas Journal of Chiropractic

thing becomes extremely clear: opioids are not recommended for long-term use unless there is objective evidence of functional improvement and pain control. In fact, the concept of a “trial” use only for opioids is mentioned prominently, and if that well-managed trial is unsuccessful in producing improvement then opioids should be discontinued."

but yet having low function and high pain is insane," reports the author.

"There are methods to use before the trial begins, including assess risks to abuse/addiction, try alternative treatments like functional restoration … and create a customized treatment plan with specific goals."

"Treating physician: In some cases, there may be a lack of education or true understanding as to the negative repercussions from chronic over-utilization of prescription drugs, or a financial incentive to continue prescribing;"

"Treatment guidelines suggest ways to determine the trial’s effectiveness (are patients getting better). To quote ODG: “Relief of pain with the use of medications is generally temporary, and measures of the lasting benefit from this modality should include evaluating the effect of pain relief in relationship to improvements in function and increased activity.” "Interestingly, ODG has 10 points for when opioids should be discontinued but only two points for when they should be continued – the patient is back to work / has improved function and has better control of pain. Using Albert Einstein’s definition of insanity, doing the same thing over and over again and expecting different results, it is fair to say that continuing to prescribe drugs 29

"So, with all of the attention and established clinical best practices and near universal opinion that opioids should not be used long-term, why is there an epidemic that only seems to grow every day? And what can realistically be done to turn the tide?"

"Patients: The expectation of no pain feeds the desire for sedation, and sometimes results in directing their own care through the treating physician (for those with more devious intentions, OxyContin street price is reputed to be up to $1 per milligram);" "Often, the treating physician is unaware of the short and long term damage the drugs are causing, or possibly just not aware of other options, or may have a patient that is demanding and the status quo is the easiest approach. Some treating physicians are motivated by incentives other than the patient’s health."

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Eat Well, Live Longer Medpagetoday.com reports that "older people who eat properly are likely to live longer. That's the implication of a study looking at mortality and eating habits among a cohort of nearly 4,000 people 65 and older …. After an average follow-up of 13 years, participants with a good diet had lower rates of all-cause and cardiovascular mortality, compared with those who had a poor diet." "For the analysis, a good diet was defined as a score of greater than 80 on the U.S. Department of Agriculture's Healthy Eating Index , while a poor score was less than 51 on the 100-point scale. A middling diet, scoring 51 through 80, was defined as 'in need of improvement.'" Researchers found "that only 18% of the participants had a diet that was above 80 in the index and those people had a 37% reduction in the risk of death, compared with those whose diets fell into the poor range." "Despite a higher prevalence of comorbidities like hypertension, diabetes, smoking, coronary artery disease, and stroke, along with the advanced age in our study cohort, a good (Healthy Eating Index) score was found to reduce the risk of death," authors noted. www.chirotexas.org

From left to right: Dr. John Wagner (founder Chiroracing), Dr. Keith Overland (ACA President), Brandon Wagner (Driver)

Chiropractic Indy Car There has NEVER been a Chiropractic sponsored Indy car in the Indy 500. But that is about to change. The ACA Endorsed, Chiropractic Sponsored, IZOD Indy car will be making its debut this year. To make it even a more historic event the Chiropractic Car will be driven by a future chiropractor--Brandon Wagner. On May 27th, for the first time in history, there will be a Chiropractor sponsored car in the prestigious Indianapolis 500, as well as races after the 500, across the country. CLICK HERE for more information and an informational video. CLICK HERE to donate. The profession is asked to contribute to this sponsorship of the Chiropractic Indy Car. This car will be seen by MILLIONS. The goal is to raise $600K! We HAVE to get Brandon out on the tracks to burn up some track time to prepare. 30

"What we are trying to do," says the team, "is get the Chiropractic profession behind this venture, as it benefits EVERYONE in the profession. They can not only watch history unfold, but can become part of it. We are getting to word out to every Chiropractor/Chiropractic Student we can, to have them step up and donate what they feel comfortable with, in order to keep the funding and momentum in place for the 2012 IZOD Indy car season." Don’t sit back and watch history unfold, BE A PART OF IT!!! So whether they are watching the race on the couch with a bad back in Florida, or with a splitting headache in Alaska, the Chiropractic Message will be displayed over and over, lap after lap! The Chiropractic sponsored Indy Car will be out of the Davey Hamilton Racing Stables (Veteran Indy 500 driver) and Sam Schmidt Motorsports.

Texas Journal of Chiropractic


Texas Chiropractic Association Professionals in Texas Protecting Chiropractic since 1916

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Mar/Apr 2012 Journal  

The Texas Journal of Chiropractic is a publication of the Texas Chiropractic Association.

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