Wednesday, September 4, 2013

Anti-Inflammatory Medications for Chronic Pain and Inflammation: They Don't Always Work Well and They May Not Be Safe


Being in pain, especially chronic pain, is debilitating.  We naturally want to do anything we can to get out of it.  Most types of pain are related to inflammation, but chronic inflammation can also cause other diseases besides chronic pain.

The last blog was on how inflammation is a necessary part of dealing with micro-organism invaders and important in the process of healing from infection and injury.  However, when inflammation does not properly stop and becomes chronic, it can cause damage to the body, such as in tendinitis, arthritis--both osteo and rheumatoid, acne, interstitial cystitis, peripheral neuropathy, autoimmune diseases, and even depression and mood disorders from inflammation of the brain and intestinal tract.  Long term chronic inflammation is at the basis of most of the chronic diseases that bring death:  cardiovascular disease, diabetes type 2, dementia and Alzheimer's, cancer and more.

Most doctors use immune suppressors and anti-inflammatory medications to stop the effects of inflammation. They work very well to reduce pain, but they don't cure the inflammation (the inflammation returns when the drugs are stopped) and their side effect profile is high.

The strongest are some of the chemotherapy drugs for cancer.  Methotrexate is a chemotherapy drug often used in rheumatoid arthritis and other autoimmune diseases to suppress the immune system. The next are biologic response modifiers, such as Enbrel.  This drug works quite well in reducing painful joints in RA and other autoimmune diseases.  The largest problem with immune suppressors is that the immune system can't do its proper job, and those using these medications are at high risk of developing a serious infection.  (For a more effective treatment for rheumatoid arthritis and sometimes other autoimmune diseases see my blog http://askdrjudi.blogspot.com/2008/01/is-there-hope-for-rheumatoid-arthritis.html)

Steriods such as prednisone are given for conditions such as arthritis, asthma and autoimmune diseases. They are also injected into joints, the spine and the epidural space of the spinal cord to reduce pain.  Again, they usually work well to reduce inflammation and pain, but they can't be used long term because of the high level of side effects and the suppression of the adrenal glands and the immune system.

Opioid pain medications are often used to reduce the symptoms of pain, but do not deal with the inflammation or the cause of inflammation.  The pain receptors become tolerant to the medications easily and often more and more medication is needed to reduce the pain.  Often it reaches the point where the pain is as bad on the medication as it was when starting the opioids.  After chronic use the pain becomes much worse when the body doesn't get it because of withdrawal symptoms.  When the body goes through withdrawal the pain is higher, so often what a person may consider as high levels of pain needing medication is only withdrawal from the medication.

There is a high physical and emotional addiction potential, and these medications are very hard to come off of.  They affect the brain and worsen mood disorders.  They are often made with acetaminophen or aspirin and taking frequent daily doses can increase the toxic affects of those.

In my experience my patients who come to me already on chronic opioid pain medication do not get better with the treatments I do until they get off of their medication.

The most common anti-inflammatory medications are the non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac, naproxen, meloxicam, etc.  These do make a difference, but in chronic pain the difference isn't as much as might be expected, as the following study shows.

In a new US study from Northwestern Health Sciences University, more than 270 adults with chronic neck pain were divided into three groups. For three months, one group received brief chiropractic sessions at least once each week, one group got instructions for simple neck exercises from a physical therapist, and one group received over-the-counter drugs such as acetaminophen or prescription drugs such as NSAIDs and muscle relaxants.

Overall, these were the percentages of the results in each group:  
Chiropractic group — 57 per cent pain reduction
Exercise group — 48 per cent pain reduction
Drug group — 33 per cent pain reduction  

In a follow-up, one year later, pain relief was still significantly higher in the chiropractic and exercise groups. Many subjects in the drug group said they needed to increase dosages and frequency to maintain the lower level of pain relief.

This study didn't have a group doing nothing.  Often up to 30% improve over time anyway.  So it is hard to tell if it was the medications working or the patient improving with their innate healing capacity.

NSAIDS have been shown to cause gastrointestinal damage, ulcers and bleeding, kidney damage and cancer, increased risk of heart problems and heart attacks, drug dependency and other side effects.  They can exhibit a "rebound" phenomena similar to the withdrawal symptoms from opioid medications, in which if a dose is missed the pain is worse not from the chronic physical problem but from the drug withdrawal.

A recent study from the Royal College of Surgeons in Ireland shows that an alarming number of patients with ischemic heart disease or cardiovascular risk factors are being inappropriately prescribed NSAIDs for RA, musculoskeletal diseases, and other chronic pain-related conditions.  Dr. Carl Orr, the lead investigator, said that the cardiovascular risks of long-term NSAID use have been well documented, but it is less well known that even short-term use increases the risk for recurrent heart attacks and death.  Diclofenac shows the highest increased risk for heart disease and heart attacks.

Acetaminophen (Paracetamol in Europe and  South America) is not a true anti-inflammatory but is most often used for pain.  Most people believe because it is an over the counter medication that it is safe.  It is true that acetaminophen has a fairly good safety profile when used in proper doses and not with alcohol or other medications which affect the liver, but liver damage can occur with misuse and overdose.  In fact, in the US acetaminophen toxicity has replaced viral hepatitis as the most common cause of acute liver failure and is the second most common cause of liver disease needing transplantation. 

Just last month, in August of 2013, the FDA issued a safety warning concerning the use of acetaminophen.  They advised that anyone who has a skin reaction such as a rash or blister while taking the drug to stop and seek immediate medical care, because of the risk of three rare but fatal skin disorders:  Stevens-Johnson syndrome, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis.

Aspirin has been the miracle drug of the last century, and when used judiciously for acute pain and inflammation can be very effective.  However chronic use can cause microscopic gastrointestinal bleeding leading to ulcers and major bleeding, abdominal pain, nausea, tinnitus (ringing in the ears), and more rarely kidney and liver damage.

If you must take one of these medications to deal with your chronic pain or chronic inflammation, take them only according to directions, take the least amount that reduces the pain, and be sure you are aware of the safety profile of the medication and how it relates to your other medical problems.

But better yet, use diet and supplementation for chronic inflammation.  The next blog will be about natural treatments for chronic pain and inflammation.

Until we meet again,
Dr. Judi


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