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Which OTC pain relievers work best for back pain?

Lauren Reiser

1 October 2010

 

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Introduction to Pain:

            Pain is a sensation that undoubtedly everyone in the entire world, with the exception of those rare individuals suffering from CIP, congenital insensitivity to pain (Thrush, 1973), has experienced at one point or another.  Pain can be physical as well as psychological.  It can last seconds or put someone in a state of agony for years at a time.   Pain is designated as either acute or chronic depending on its nature.  Acute pain generally results from soft tissue damage, infection or inflammation.  This pain is severe and localized, often indicating injury to the body.  Alternately, chronic pain may have no apparent cause and lasts for very long periods of time. Chronic pain is vaguely described as pain lasting 6 months or longer.  Some professionals refer to chronic pain as the disease of pain.  In many cases this condition is not curable, only treatable. (http://www.spine-health.com/conditions/chronic-pain/types-back-pain-acute-pain-chronic-pain-and-neuropathic-pain#chronic.)

For pain management doctors prescribe various remedies ranging from drug therapies to physical therapies.  Drugs can be either prescription or over-the-counter (OTC), depending on the severity of the pain and the duration for which the drug is to be used for.  The type of pain one suffers from also determines the method of pain management prescribed.  Some drugs work magnificently for one type of pain but have little or no effect on others.  If a patient prefers not to use drugs, for reasons such as the potential for developing side effects and addiction, or needs additional pain alleviation, doctors recommend hot and cold compresses, special exercises, physical therapies and dietary changes. 

            In particular, for patients suffering from chronic back pain, doctors primarily recommend over-the-counter drugs.  Since this pain is chronic, prescription drugs are only used when absolutely necessary because of the risks of addiction and abuse.  In addition to OTC drugs, doctors prescribe spinal manipulation treatments, epidural steroid injections as well as exercises (http://www.ehealthmd.com/library/backpain/BAK_treatment.html).  Recent studies by Lippincott Williams and Wilkins 2010, have found pulsed radio frequency to have successfully relieved chronic pain resulting from various conditions, including lower back pain.  However, over-the-counter drugs remain the most commonly prescribed method for relieving chronic back pain.

            In order to decide which OTC pain medication works best, a comparative drug study must be preformed.  Certain drugs work better for certain types of pain.  To determine which works best, various OTC drugs must be given to a group of people all presenting similar symptoms of chronic back pain; the results can then be compared to verify the potency of each drug.

            This literary review will address the question of which OTC drug works most effectively in relieving chronic back pain while also discussing the long-term side effects of using this drug.

 

Living With Chronic Back Pain:

The relatively prevalent condition of chronic back pain has many discrepancies among professionals as to how it should be defined.  While some explain that it is back pain lasting longer than 7-12 weeks, others argue that it is pain that lasts longer than the expected recovery time; furthermore other professionals describe it as recurrent phases of intermittent pain for a long duration of time (Anderson 1999).

The 1988 National Health Interview Survey (1985-88) used by Praemer 1992, reveals information on the frequency of chronic pain and the types of impairment it caused in the United States.  According to the survey, women experienced higher rates of spine and back impairments with a prevalence of 70.3 per 1000 compared to 57.4 per 1000 in men.  Different ethnicities also show variations in prevalence as Caucasians maintain a rate of 68.7 per 1000 compared to African-Americans’ prevalence of 38.7 per 1000.  In total, spine and back impairments caused over 185 million days of confined activity for the patients involved during the three year period; for 83 million of the 185 million days the sufferers were bed-ridden. 

Cross-sectional studies have found a correlation between negative psychological factors and the occurrence of chronic low-back pain (Anderson, 1997).  Anxiety, depression, somatisation symptoms, stressful responsibility, job dissatisfaction, mental stress, negative body image, weak ego, and poor drive satisfaction all have associations with the development of back problems.  In some prospective studies these factors even predicted the development of back-pain in patients who were not yet diagnosed. 

In a study of 200 chronic-low back pain patients entering a functional rehabilitation program, results reveal that 77% of those effected met the lifetime diagnostic criteria for at least one psychiatric diagnosis and 59% exhibited current symptoms of a psychiatric disorder; common disorders included depression, substance misuse, and anxiety disorders (Polatin, Kinney, Gatchel, Lillo, Mayer, 1993).  The study explained that 54% of the patients with depression, 94% suffering from substance abuse and 95% exhibiting anxiety disorders had experienced their psychiatric problems prior to the onset of their chronic lower back pain.  The high rates of correlation between substance abuse and anxiety disorders with chronic back pain implies that these disorders precede the physical symptoms of chronic back pain; in contrast, depression may develop prior to or as a result of chronic back pain.

            In general, back pain recovery maintains a positive prognosis with over 90% of patients improving within 3 months; however, for those whose pain persists longer than 12 weeks, and would thus meet the criteria for being chronic, the restoration process is slow and uncertain (Anderson 1999).   Chronic back pain is not only physically incapacitating but also psychologically debilitating.  The costs of treatment remain high and unquestionably arouse fear in patients as to how they will compensate for their medical bills; there is no doubt as to why this alone can cause psychiatric disorders in those not already affected.

            Treating chronic back pain involves various methods including drug treatment, electrotherapy, surgical procedures as well as exercises.  Because chronic pain is persistent and usually incurable, drug therapy in the form of painkillers remains the least evasive, most effective and most accessible form of treatment (Chou, Hoyt Huffman, 2007).

 

Types of OTC Painkillers:

            The easy accessibility of OTC drugs implicitly reveals that they are less detrimental to one’s health than are prescription drugs.  The long-term impacts of prescription drugs can be fatal and severely damaging to the quality of one’s life; while OTC drugs do come with potential risks, they are still the better option.

            Typically, over-the-counter painkillers fill the medicine cabinets of every American household.  These drugs include Aleve, Advil, Tylenol, Bayer’s and many more.  Though composed of entirely different chemical compounds, each drug works to achieve the same goal: pain relief.

            Aleve, which is the generic name for naproxen, belongs to a group of painkillers called NSAIDs (nonsteroidal anti-inflammatory drugs.) It is generally prescribed to relieve symptoms of osteoarthritic pain, particularly ankylosing spondylitis, which affects the spine.  As the term NSAIDs indicates, naproxen works to relieve inflammation as well as reduce fever; it does so by blocking the chemicals that cause these maladies. Naproxen comes in both prescription and nonprescription forms; the nonprescription drug can be taken orally every 8-12 hours as a tablet or as a gelatin-coated pill.  It is advised to take this pill with food or milk to prevent nausea.

            The short-term side effects of naproxen range from mild to severe and affect multiple organ systems.  They include disruptions in the gastrointestinal tract such as constipation, diarrhea, and gas, and may also produce oral sores or excessive thirst.  Headaches, dizziness, drowsiness and difficulty falling/staying asleep are also common.  Other more serious side effects include changes in vision, unexplained weight gain, rashes and blistering, swelling of the eyes, face, lips, tongue, throat, arms, hands, feet, etc; these complications must be reported to a physician immediately

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000526.

            Ibuprofen, commonly known as Advil, Motrin, or Midol, also belongs to the NSAID group and therefore acts in a method similar to naproxen.  In addition to alleviating arthritic pains, ibuprofen relieves menstrual cramps, fever, common cold pains, toothaches and backaches. Nonprescription doses come in the form of a tablet, chewable tablet, liquid, or drops, making it a good option for children 12 years and older.  Ibuprofen should be taken every 6 to 8 hours as needed; however, one should not exceed 4 doses in a 24-hour period.  Side effects include constipation, diarrhea, gas or bloating, dizziness, nervousness, or ringing of the ears.  More serious side effects range from aggression and confusion to difficult or painful urination, jaundice and excessive tiredness http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000598.

            Acetaminophen, generically called Tylenol, is classified as an analgesic and antipyretic http://www.medicinenet.com/analgesics_antipyretics/glossary.htm.) This drug works by altering how the body perceives pain and by changing the body’s cooling system.  Acetaminophen uses include headache, muscle ache and menstrual cramp relief, as well as treats cold symptoms, toothaches, backaches and reactions to vaccines. Acetaminophen forms include tablet, chewable, capsule, liquid, drops, extended-release and an orally disintegrating tablet.  It is also possible to inject this drug through a rectal suppository.  Side effects are less broad than NSAIDs and include rashes, hives, itching, swelling, hoarseness and difficulty breathing or swallowing.  Combining Acetaminophen with caffeine and aspirin has been successful in alleviating migraine pain. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000521. Overdose of this drug can lead to extreme liver damage; therefore, one should not ingest more than 1000 mg per day.  Drinking more than 3 alcoholic per day increases the risk of liver damage.  http://www.drugs.com/acetaminophen.html

            Aspirin, another typical OTC painkiller, belongs to the group of drugs called salicylates.  Nonprescription doses are prescribed especially to prevent heart attacks in high-risk patients, such as those who have had a heart attack in the past or experience angina.  It is also used in prevention of ischemic strokes, which occur when a blood clot blocks blood flow to the brain, but has no effect on hemorrhagic strokes, those caused by bleeding in the brain.  Doses come in the form of regular tablets, a delayed-release tablet, a chewable tablet, a gum and a rectal suppository.

 If prescribed as a preventative measure, Aspirin should be taken once daily; if used to relieve inflammatory pain or fever, it should be taken every 4 to 6 hours as necessary. Caution must be taken when giving children Aspirin due to the risk of Reye’s syndrome, a dangerous condition in which fat builds up in the brain, liver or other organs if a child ingests Aspirin and has a virus.  Side effects include nausea, vomiting, stomach pains and heartburn; more serious side effects such as fast heartbeat, bloody vomit, cold clammy skin, difficulty breathing should be reported to a doctor immediately. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000802

 

Which Pill to Pick?

Comparative drug studies reveal which OTC painkiller works best for treating chronic back pain. Roger Chou, MD and Laurie Hoyt Huffman, MS (2007) performed a study to compare the benefits and harms of acetaminophen, NSAIDs and other non- OTC drugs in relieving this condition. To obtain their results, these researchers examined the MEDLINE (1966 through November 2006) and Cochrane Database of Systematic Reviews (2006, Issue 4) for reviews that focused on lower back pain.  Their research included systematic reviews of randomized, controlled trials that met the following criteria: reported in English or included in an English language systematic review, evaluated adults 18 and over that were not pregnant, evaluated a target medication, and reported one of the following outcomes: back-specific function, generic health status, pain, work disability, or patient satisfaction (Bombardier, 2000, Deyo, Battie, Beurskens, Croft, Koes, 1998). 

Within their studies, Chou and Huffman found several relevant and high-quality trials testing acetaminophen in chronic back pain relief and concluded that this particular drug was inferior to NSAIDs.  In their studies of NSAIDs, the researchers found ibuprofen to be superior to the placebo, thus designating the NSAID category the most effective type of OTC drug. 

            In a study of NSAIDs’ effectiveness on low-back pain, prepared and maintained by the Cochrane Library (2007), researchers considered randomized and double-blind controlled trials meeting the following criteria: subjects 18 or older, treated for non-specific back pain with or without sciatica, excluding subjects with low-back pain due to infection, arthritis or other pathological conditions, and either acute or chronic pain patients.  The review concluded “NSAIDs are slightly effective for short-term symptomatic relief in patients with acute and chronic low-back pain without sciatica (pain and tingling radiating down the leg)”(Roelofs, Deyo, Koes, Scholten, van Tulder,2007).

            In an article on the evaluation and management of chronic low back pain Last, and Hulbert, 2009 recommend acetaminophen and NSAIDs as the first method of treatment.  These researchers as well as many others acknowledge that NSAIDs are usually more effective than acetaminophen but have significantly negative effects on the gastrointestinal and renovascular systems (Chou, Qaseem, Snow, et al, 2007).

            In a double-blind study of patients with anklosing spondylitis, a type of arthritis effecting the spine, naproxen, a NSAID, was as effective as aspirin in ameliorating night pain, morning stiffness and pain while at rest; it also produced fewer side effects (http://www.drugs.com/pro/naproxen.html).

 

Pain Relief, But at What Cost?

            Controlled and reliable studies revealed that NSAIDs were the medicine of choice when treating chronic back pain; however, each study also acknowledged serious side effects and problems that occurred with long-term use.

            NSAIDs have been known to cause fatal gastrointestinal complications ranging from stomach pain to ulcers.  The most serious side effects are symptomatic or complicated ulcers with bleeding, perforation, or obstruction (Ramosekh D, Van Leerdam ME, Rauws EAJ, et al, 2005).  Each year, long-term NSAID use is responsible for almost 103,000 hospitalizations and 16,5000 fatalities, a rate higher than the mortalities resulting from AIDS and cervical cancer in the United States (http://www.sciencedaily.com/releases/2005/01/050111123706.htm). Approximately 1-4% of frequent NSAID users develop serious gastrointestinal tract complications annually (Silverstein FE, Faich G, Goldstein JL, et al, 2000).

While NSAIDs provide a multitude of benefits for patients suffering from chronic back pain, their risks include significant gastrointestinal, renal, and cardiovascular problems.  In prescribing NSAIDs, clinicians must consider the patient’s cardiovascular and gastrointestinal risk factors; they should also prescribe the lowest effective dose for the shortest period of time (Wilcox, et al, 2006). Through monitored use of coxibs, which are NSAIDs known to cause fewer GI side effects, and gastroprotective therapies it is possible to lessen the risks, although they will not be removed entirely (http://medical-dictionary.thefreedictionary.com/Coxib).

            NSAIDs seem to have even further detrimental effects on the elderly population.  The effects are so severe that doctors recommend opiate use rather than NSAIDs.  Elderly men and women have different reactions to the absorption of NSAIDs than do younger populations; this variation makes NSAIDs highly dangerous.  The geriatrics society advises elderly individuals to use NSAIDs with “extreme caution” (Description: :WA1-1.jpghttp://newoldage.blogs.nytimes.com/2009/05/06/experts-warn-against-long-term-use-of-common-pain-pills/).

 

 

 

 

 

 

 

 

 

 

 

What’s a Person to Do?

            The answer all chronic pain sufferers aim to discover is: what can I do? The drug market presents a myriad of options and there exists even more alternative treatment methods each claiming to effectively treat chronic pain; but how can a common citizen choose the best option on their own? Comparative drug studies have shown NSAIDs to be most potent in alleviating pain yet the problems they solve create other issues in the form of side effects.  NSAIDs maintain extremely dangerous risks especially in people with pre-existing conditions and in geriatric patients.  Studies can give the scientific benefits of drugs and recommend one over another but it is the patient’s job to analyze the pros and cons of using this particular medicine.  A patient must decide if the alleviation of never-ending pain is worth the potential for developing serious gastrointestinal problems.  If chronic back pain is truly disrupting one’s life they are more likely to risk the side effects in exchange for a better standard of living.  Pain is a very simple symptom with a very confusing and complex methodology of treatment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Literature Cited

Andersson, GBJ. (1999). Epidemiological features of chronic low-back pain. Lancet, 354.

Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10470716

Andersson, GBJ. (1997). The epidemiology of spinal disorders. In: JW Frymoyer, Editor,

The adult spine: principles and practice, 2nd ed., Lippincott-Raven, Philadelphia pp. 93–141.

Bombardier, C. (2000). Outcome assessments in the evaluation of treatment of spinal

disorders: summary and general recommendations. Spine, 25 (24), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed

Bombardier C, Laine L, Reicin A, et al. (2000). Comparison of upper gastrointestinal

toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. New England Journal of Medicine;343:1520–1528

Chou, RC, Huffman, LH. (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. Annals of American Medicine, 147 (7), Retrieved from http://www.annals.org.proxy.library.vanderbilt.edu/content/147/7/505.long-

Chou  RC, Qaseem  A, Snow  V, et al., for the Clinical Efficacy Assessment

Subcommittee of the American College of Physicians, American Pain Society Low Back Pain Guidelines Panel.  Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society [published correction appears in Ann Intern Med. 2008;148(3):247–248]  Ann Intern Med.  2007;147(7):478–491.

Deyo RA, Battie M, Beurskens AJ, Bombardier C, Croft P, Koes B, et al. (1998).

Outcome measures for low back pain research. A proposal for standardized use. Spine. 24(4), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed

Hernández-Díaz S, Rodríguez LA. Association between nonsteroidal anti-inflammatory

drugs and upper gastrointestinal tract bleeding/perforation: an overview of epidemiologic studies published in the 1990s. Arch Intern Med.

Kearney PM, Baigent C, Godwin J, Halls H, Emberson JR, Patrono C. Do selective

cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ. 2006;332:1302-8.

Polatin, PB, Kinney RK, Gatchel, RJ, Lillo E, Mayer, TG. (1993). Psychiatric illness and

chronic back pain. The mind and the spine—which goes first?, Spine (18) pp. 66–71.

Praemer, A Furnes, S Rice, DP. (1992). National Health Interview Survey

Musculoskeletal conditions in the United States., AAUS, Rosemont, pp. 1–99.

Ramosekh D, Van Leerdam ME, Rauws EAJ, et al. (2005). Outcome of peptic ulcer

bleeding, nonsteroidal anti-inflammatory drug use and Helicobacter pylori infection. Clinical Gastroenterol Hepatol;3: 859 – 864.

Roelofs PDDM, Deyo RA, Koes BW, Scholten RJPM, van Tulder MW. Non-steroidal

anti-inflammatory drugs for low back pain. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD000396. DOI: 10.1002/14651858.CD000396.pub3.

Silverstein FE, Faich G, Goldstein JL, et al. Gastrointestinal toxicity with celecoxib vs.

nonsteroidal anti-inflammatory drugs for osteo- arthritis and rheumatoid arthritis: the CLASS study: a randomized controlled trial. Celecoxib Long-Term Arthritis Safety Study. JAMA 2000;284:1247–1255

Snidyongs, S. (2010). Pulsed radio frequency: a non-neurodestructive therapy in pain

management. Pain and Anesthesia Research Centre, 4(2), Retrieved from http://www.ncbi.nlm.nih.gov.proxy.library.vanderbilt.edu

Thrush, D.C. (1973). Congenital insensitivity to pain: a clinical, genetic and

neurophysiological study of the same family. Oxford Journals, 96, 369-386.

Van Tulder MW, Scholten RJ, Koes BW, Deyo RA. Nonsteroidal anti-inflammatory

drugs for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 2000;25:2501-13.

American Gastroenterological Association (2005, January 16). Study Shows Long-term Use Of NSAIDs Causes Severe Intestinal Damage. ScienceDaily. Retrieved September 29, 2010, from http://www.sciencedaily.com

Wilcox, C.M. (2006). Consensus development conference on the use of nonsteroidal anti-

inflammatory agents, including cyclooygenase-2 enzyme inhibitors and aspirin. Clinical Gastroenterology and Hepatology, 4, 1082-1089.

 

 

 

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