Pitfall #1 of medical integration: some practices that called themselves “medically integrated” were actually running opioid mills disguised as pain management clinics — and the fallout changed what an entire profession was allowed to do.
By Dr. Michael Carberry, DC — President, Advanced Medical Integration
This is the first in a series on the pitfalls of medical integration — the mistakes that turn a genuinely integrated practice into something closer to a liability. Pitfall number one is the most serious: abandoning your philosophy as a chiropractor in exchange for reimbursement.
What Happened in Tennessee
I never lived in Tennessee, but I’ve had practices there, and when I first arrived, something stood out immediately: an unusual concentration of pain management clinics. Nothing wrong with pain management on its own. What was wrong was the business model behind a specific cluster of them.
The pattern worked like this. A patient would come in, get started on opioids, and come back for refills. At some point, the nurse practitioner would tell them the prescription wasn’t available anymore unless the patient agreed to a procedure — specifically, an SI (sacroiliac) joint injection. SI injections reimbursed well and were simple to perform, so the clinic had every financial incentive to do a lot of them. The patient, meanwhile, kept coming back, because they needed the refill. Addiction wasn’t a side effect of this business model. It was the retention strategy.
What made this particularly hard to stomach: a lot of these clinics were owned by chiropractors. There was a consulting company in Tennessee actively teaching chiropractors how to convert their practices into exactly this kind of pain management clinic — stop adjusting patients, start running injections, and use opioid dependency to guarantee compliance and repeat visits.
It got bad enough that the Tennessee Board of Nursing ultimately stripped nurse practitioners of the authority to perform SI injections in the state — a direct regulatory response to how badly this particular business model had been abused. Nurse practitioners who had nothing to do with these clinics lost a tool they’d previously been trusted to use, because a specific group of operators ran it into the ground.
Not All Pain Management Is the Problem
To be clear, pain management as a discipline isn’t the issue, and plenty of practices that monitor patients carefully and use medication appropriately are doing legitimate work. The issue is a specific business model: using a controlled substance’s addictive potential as a mechanism to guarantee patient retention. That’s a different thing entirely from treating pain responsibly, and the two shouldn’t be confused with each other.
Where “Opioids Aren’t Addictive” Actually Came From
Part of how this business model got normalized industry-wide traces back to how confidently the pharmaceutical industry asserted that opioids carried a low risk of addiction. The real origin of that claim is worth knowing, because it’s more damning than any single bad consulting company: in 1980, the New England Journal of Medicine published a five-sentence letter — not a clinical trial, a letter — from researchers Jane Porter and Hershel Jick, reporting that addiction was rare among a group of hospitalized patients who had been given narcotics under medical supervision (Porter & Jick, 1980). That narrow observation, about short-term, monitored, in-hospital use, got cited for decades afterward — including in pharmaceutical marketing materials — as if it were general proof that opioids were safe from addiction in any setting. It wasn’t that kind of study, and it was never designed to support that kind of claim. A lot of what gets presented to prescribers as “evidence-based” traces back to exactly this kind of citation stretched well past what it was built to support.
The Point of This Pitfall
If a practice’s business model depends on a patient’s addiction to function, that practice has stopped practicing chiropractic, whatever the sign on the door says. Integration is supposed to mean escalating from the least invasive, most functional approach outward — not opening a side business that profits from dependency. If you’re going to run a clinic on that model, the honest thing to do is give up the chiropractic license, because it isn’t what this profession is built on.
Done right, medical integration means the opposite of this story: physical medicine, functional care, and conservative treatment first, with medical collaboration used to support that goal — not to monetize a patient’s inability to stop.
Frequently Asked Questions
What is a “pain mill,” and how does it relate to chiropractic integration?
A pain mill is a clinic whose business model depends on patients returning repeatedly for a controlled substance, often using a secondary procedure (like an injection) as a condition for continuing the prescription. When a chiropractic practice converts to this model, it has abandoned chiropractic’s core philosophy of conservative, function-first care in favor of a reimbursement strategy built on dependency.
Why would a chiropractor’s clinic start performing SI injections instead of adjustments?
In the business model described above, SI injections were simple to perform and reimbursed well, while also giving the clinic a reason to require the patient’s continued attendance. That financial incentive — not clinical necessity — drove the shift away from adjustments and toward injections.
Is all pain management bad for an integrated practice?
No. Pain management delivered responsibly, with appropriate monitoring and medically necessary use, is legitimate care. The problem described here is specific: using a substance’s addictive potential as a deliberate retention mechanism, not pain management as a category.
Where did the claim that “opioids aren’t addictive” actually come from?
A significant part of it traces back to a 1980 five-sentence letter in the New England Journal of Medicine by Porter and Jick, which reported low addiction rates among hospitalized patients given narcotics under medical supervision. That narrow finding was later cited far beyond its original scope — including in pharmaceutical marketing — to suggest opioids broadly carried minimal addiction risk.
What happened when regulators caught on to this business model?
In Tennessee, the abuse of SI injections tied to opioid retention became significant enough that the State Board of Nursing revoked nurse practitioners’ authority to perform SI injections altogether — a regulatory consequence that affected the entire profession in that state, not just the clinics responsible for the abuse.
Want to build an integrated practice the right way? Reach out to Advanced Medical Integration at www.amidoctors.com or discover@amidoctors.com, or find us on YouTube at Advanced Medical Integration.
Sources
- Porter J, Jick H. “Addiction Rare in Patients Treated with Narcotics” (letter). New England Journal of Medicine, 1980. org/10.1056/NEJM198001103020221
- Subsequent citation-pattern research tracking how the Porter & Jick letter was used in opioid marketing and prescribing literature (specific follow-up citation to be confirmed before publishing — a rate limit on this session’s research tool prevented verification)
- Tennessee Board of Nursing policy change on nurse practitioner authority to perform SI injections (firsthand account from Dr. Carberry — a specific regulatory citation should be added if this detail needs to stand up to reader fact-checking)
About the Author
Dr. Michael Carberry, DC, is President and founder of Advanced Medical Integration (AMI), which has grown to more than 1,000 independent practices across the U.S. and has been named to the Inc. 5000 for five consecutive years. Dr. Carberry holds a B.S. in Marketing from Stockton University and a Doctor of Chiropractic from Life University, and is the author of The Death of American Healthcare. He speaks nationally on healthcare, business, economics, and the opioid crisis, and serves as a trustee for Delphi Schools Inc.