Back Pain Part II - Drugs
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Back Pain Part II - Drugs

In Part 1 I discussed the non pharmacologic. Yet, the most practical approach to treating chronic pain may be combining the non pharmacologic with the pharmacologic [i]. This is because Western drugs. are easy and accessible compared to the non pharmacologic alternatives. However, of the many drugs used for pain management, the evidence remains insufficient to identify one drug as offering a clear advantage [ii]. The drugs with the best evidence of effectiveness are:

  • Acetaminophen (acute pain)
  • NSAIDs (acute pain)
  • skeletal muscle relaxants (acute pain
  • tricyclic antidepressants (chronic pain)


CATEGORIES OF DRUGS
Three main category of drugs, along with opiates are used for different types of pain and under different circumstances as follows:

Acetaminophen. 
Tylenol is the first drug recommended for non-inflammatory pain.  There are hundreds of different types of painful joint diseases, other than osteoarthritis (OA), and rheumatoid arthritis (RA) under the umbrella term "arthritis".  Inflammation is the one common thread between all types [iii]. Tylenol is best suited for osteoarthritic pain, which is associated with very little inflammation. 

Tylenol is less likely to cause gastric ulcers and GI bleeding compared to the non steroidal anti-inflammatories (NSAIDs). This is important when pain medication is taken around the clock- before pain becomes too severe.
Tylenol should be used with caution in those with hepatic disease, and with alcohol consumption. 
 
NSAIDS & Aspirin 
The first drugs recommended for inflammatory pain are the COX I Non-steroidal anti-inflammatory drugs or NSAIDs (e.g. Ibuprofen); the COX II Selective NSAID (e.g. Celebrex, Celecoxib); and salicylates (aspirin). A person's  response to any one of the NSAIDs does not predict response to another [iii]. While the analgesic effect of NSAIDs and aspirin should be noted within 1 to 4 hours of administration, the full inflammatory pain-relieving effect may not be apparent for 1 to 3 weeks [ii].

The side effects of COX I NSAIDs and aspirin are gastric erosion, ulcers & GI bleeds, and renal injury. The risk of bleeding is very low in young healthy adults; and high in the elderly [iii]. Their use should be delayed 24-hours after traumatic musculoskeletal injury because their anti-platelet affect increases the risk for bleeding. And they are contraindicated until after the third trimester, because they may cause bleeding and miscarriage.

COX II NSAIDs do not cause the bleeding, and GI problems that COX I NSAIDS do, but they should not be used by those with cardiovascular disease. Celecoxib can not be used by those who are allergic to sulfa drugs. Ibuprofphen, and NSAIDS in general can cause fluid retention.

Aspirin should never be used in children with influenza or chicken pox (varicella) because it causes Reye's syndrome, which has a 20 to 30% mortality rate [ii]. Aspirin can also exacerbate asthma, and cause temporary hearing loss. Aspirin is not recommended during pregnancy because it is has a teratogenic effects on the fetus. Both aspirin and NSAIDs are excreted in breast milk. 

Opiates/Narcotics
Opiates are prescribed for severe pain, acute pain, and pain of terminal diseases. While increasing the dose of other drugs has progressively smaller incremental effect on pain relief (point of diminishing return), opioid do not have this "ceiling effect". However, over time the body still develops tolerance, which means it require higher doses of an opoid for effective pain relief. At this point there is the risk of physiological, and psychological dependancey; and potential for abuse. This is why Opoids are thrid-line drugs for chronic pain relief. Opoid analgesics cause constipation and are associated with nausea, vomiting, and itching.

Methadone is sometimes prescribes for irretractable pain. This practice is very alarming because methadone is highly addictive {it is the synthetic form of as heroin]. While methadone was designed to help people detox off of heroin, a person will have just as hard time coming off this medication!

Muscle Relaxants & Anti-spasmodics
Valium and Flexaril are used for the muscle spasm and insomnia that may accompany pain. While valium, a benzodiazapine, is a very good muscle relaxant it has serious potential for dependency and abuse. Flexaril, which is a cousin to the tricyclic antidepressants, shares their cholinergic and central nervous system side effects: blurred vision, dry mouth, constipation, urinary retention, interocular pressure, drowsiness, tremors/ seizures. Flexaril also interacts with Tramadol (a partial-opoid agonist) and Naproxen (NSAIDS) both of which are commonly used pain medications. 

GOALS & PROGNOSIS
The goal of chronic pain management in Western medicine is to resolve or reduce pain well enough so that an individual can maintain a quality of life & functionality (without necessarily achieving 100% relief). Secondary goals is to manage, slow, reverse the progressive of any degenerative changes. The prognosis depends on the cause and nature of the pain.

It is interesting to note that "In over 85% cases of chronic low back pain, the cause is ‘non-specific’, and in many cases is associated with other chronic symptoms" [iv]. These chronic symptoms are called the neuromatrix of pain and include depression, poor appetite, low libido, irritability, fatigue, and insomnia etc. 

It is theorized that this neuromatrix is due to less connectivity between the areas of the brain that control emotions, mood, and perception & response to pain (threatening stimulus). Acupuncture treatments correlated with an increases in connectivity between these areas of the brain, and a reduction in pain [iv]. In other words, acupuncture is good for the non-specific causes of pain!

With acupuncture, the goal is at least a 30% pain reduction with the first treatment; and stronger or more lasting pain relief with subsequent treatments. How long this pain relief lasts (hours, days, weeks) determines the interval of time needed between treatments. The secondary goal is to improve overall condition and constitution- the root cause of the problem. Both can be enhanced with the addition of herbs- possibly concurrent use with lower doses of medication. 

The complete resolution of pain depends on its cause & nature, as well as the techniques used by the practitioner. A practitioner my treat a multiple times for fair to moderate pain relief. Then after re-evaluating the diagnosis and treatment plan, achieve adequate to complete pain relief for the patient. Sometimes it all boils down to a multi-step process- treating the whole person and not just the pain.

 
You need Flash Player in order to view this.
Acupuncture for Sciatica
Paul Brecher BA FAcS MPCHM Principal of The College of Chinese MedicinePaul Explains to his students how to use acupuncture to treat sciatica of the right leg.





References
[i] Beach, P., (2008). Management of chronic pain. Clinical Journal of Oncology Nursing
12(1), 161 - 163.
[ii] Chou, R. & Huffman, H. (2007). Medications for acute and chronic low back pain: A
review of the evidence for an American Pain Society/American College of Physicians clinical practice  guideline. Annual of Internal Medicine, Clinical Guidelines 147, p. 505-514. 
[iii] Edmunds, M., Winterton, M. & Maren, S. (2013). Pharmacology for the primary care
provider (4th ed.). St. Louis, MO: Elsevier Mosby.
[iv] Li, Zhang, Yi,Tang, Wang & Dong.  (2014). Acupuncture treatment of chronic low
back pain reverses an abnormal brain default mode network in correlation with
clinical pain relief. Acupuncture Medicine 32. 102-108 doi:10.1136/acupmed2013-010423. Retrieved from   http://aim.bmj.com/content/32/2/102.full







































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