ibuprofen

New Research Dividing Physicians Over NSAIDs For Chronic Pain

/ Thomas Cohn, MD

NSAIDsWhen you suffer an injury, it causes an inflammatory reaction inside the body, and if the problem isn’t treated correctly, this inflammation can linger. The prevailing understanding when it comes to chronic pain is that it is caused by chronic inflammation, which is why many specialists try to prevent the problem by working to control inflammation. Anti-inflammatory medication like Ibuprofen has been a common recommendation for decades as a way to effectively manage inflammation and work to reduce the risk of it becoming chronic.

However, new research seems to suggest that attempting to drown out this inflammation with anti-inflammatory medications before it gets out of control may not be providing the benefits we assume it does. In fact, they believe short-term use of these Non Steroidal Anti-Inflammatory Drugs (NSAIDs) may actually increase your risk of chronic pain in the long term, and that claim is dividing the medical world.

Ibuprofen And Chronic Pain

The new research suggests that the initial inflammation that develops after an injury may be necessary for the body to make a full recovery. If this suggestion is true, it could shatter the decades-old standard of treating pain with aspirin, ibuprofen or IV steroids at the hospital. By drowning out this necessary initial inflammation, researchers suggest NSAIDs may actually be putting patients at a greater risk for developing chronic pain.

“For many decades it’s been standard medical practice to treat pain with anti-inflammatory drugs. But we found that this short-term fix could lead to longer-term problems,” says Jeffrey Mogil, a Professor in the Department of Psychology at McGill University and E. P. Taylor Chair in Pain Studies. “Neutrophils dominate the early stages of inflammation and set the stage for repair of tissue damage. Inflammation occurs for a reason, and it looks like it’s dangerous to interfere with it.”

Now, it’s worth noting that not everyone agrees with the research, at least not without additional evidence. The paper was rejected from the New England Journal of Medicine after one reviewer wrote that he would not “overturn decades of medical practice,” until additional convincing evidence was presented.

Even if the findings are true, as we’ve said countless times on our blog in the past, it may only hold true for a subset of patients because chronic pain is so unique to the individual, and what works for one patient may not work for others. For example, the shock and inflammatory response of an ankle sprain and a surgery vary greatly, and assuming this research applies unilaterally to both of these groups could lead people down the wrong treatment path.

So while the jury is still out on whether or not NSAIDs may be having some unintended consequences for our ability to help pain resolve, the good news is more research is being poured into how to best handle chronic pain, and that’s a great thing. The more we learn, the better we can help each patient.

If you need help with a chronic pain issue, reach out to Dr. Cohn’s office today at (952) 738-4580.

Common Non-Opioid Pain Medications

/ Thomas Cohn, MD

pain medsThe most common medications prescribed by primary care physicians for pain are analgesics.  They can be divided into to two main categories: opioids/narcotics and non-opioid type medications. We have discussed opioids at length in previous blogs. This article will cover common non-opioid pain medications.

Acetaminophen/Tylenol

Acetaminophen/Tylenol works for mild to moderate pain, such as headaches. It works by enhancing the body’s inhibitory pain pathways.  The maximum safe dose was considered to be 4000 mg, but data now available is questioning that level.

Breakdown products of acetaminophen can be toxic to the liver, especially when the liver has other compounds to metabolize.  Alcohol can greatly interfere with acetaminophen breakdown, and when toxic it can kill the liver, and has been found to be the most lethal nonprescription medication sold. In short, be careful when taking this medication with alcohol.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) are some of the most prescribed pain medications.  Common examples include:

  • Ibuprofen
  • Naproxen
  • Aspirin
  • Diclofenac
  • Celebrex

These medications inhibit enzymes that are released from cells when they are injured and inhibit inflammation and secondarily peripheral pain receptors.  These drugs act on the “COX” enzymes.

  • COX 1 enzymes protect the gut, maintain kidney function, and cause platelets to form clots.
  • COX 2 enzymes are involved in inflammation.

Most NSAIDs are nonselective, impacting both COX 1 and2 enzymes, and therefore can cause stomach damage, bleeding and kidney problems.  NSAIDs are used for joint pain and pain after injury.

Corticosteroids

Corticosteroids are medications that include:

  • Prednisone
  • Hydrocortisone
  • Injectable steroids

These medications only work on inflammation.  They are very powerful, and can be used in a number of ways.  Topically they are used for rashes.  Orally and via injection they can bring down local or diffuse inflammation.  They have been injected in joints to bring down joint pain, and often are used by pain physicians as epidural injections to treat spinal pain causing radiculopathy.  Unfortunately, if not used with caution, they can have numerous side affects due to affecting hormone balance.

Muscle relaxers and anti-spasm medications

Muscle relaxers and anti-spasm medications are used to reduce muscle tightness.  Most of these drugs have no impact on pain, and may act by sedating a person.  These medications may help pain that is due to muscle tightness beyond what is necessary.  Some of them are very addictive, since they include Valium and similar anxiety medications. In chronic pain, most of these medications are ineffective.  Other muscle relaxers commonly used include Robaxin, Skelaxin, and Norflex.  These medications are sedating and some may be addicting, but generally have very little affect in overall pain.