Your Health Checkup: Death Knell for NSAIDs?

New observations suggest that early NSAID treatment actually leads to prolonged pain.

Back pain

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“Your Health Checkup” is our online column by Dr. Douglas Zipes, an internationally acclaimed cardiologist, professor, author, inventor, and authority on pacing and electrophysiology. Dr. Zipes is also a contributor to The Saturday Evening Post print magazine. Subscribe to receive thoughtful articles, new fiction, health and wellness advice, and gems from our archive. 

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Chronic low back pain is one of the most common disabling physical conditions and is a major problem worldwide; its prevalence and burden increase with age. As an “older adult,” I experience back pain along with the usual muscle and joint aches — shoulder, knee, finger, and so on — that accompany the aging process. Since the cause most often is from inflamed tissues or joints, I usually treat with a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen (Advil, Motrin, others) or naproxen (Naprosyn, Aleve, others). I avoid diclofenac (Voltaren; see below). Most times the NSAID relieves the pain of the acute episode, but I, like many others, have resigned myself to the likelihood that such soreness will recur and become a chronic condition.

New observations suggest that early NSAID treatment actually leads to prolonged pain despite acute relief, an outcome that does not happen when pain relievers without anti-inflammatory properties are used.

How could that occur? It seems counterintuitive since inflammation is the culprit causing the pain and NSAIDs relieve inflammation.

Recent experiments in animals and humans have found the answer. At the time of the acute pain, multiple complex and transient biological processes occur, including activation of a specific kind of white blood cell (neutrophil) that ordinarily helps fight infection. The activated neutrophil elevates the initial acute inflammatory response. This critical reaction helps the body adapt and trigger responses that prevent a later chronic stage of inflammation and pain. Inhibition or impairment of these initial inflammatory reactions by anti-inflammatory drugs like NSAIDs, in subjects with acute back pain for example, impaired the adaptive response and increased the risk of developing chronic pain, despite pain relief at early time points.

Because the beginning of the inflammatory process programs its subsequent resolution, initial treatment for pain with NSAIDs becomes counterproductive.

A second reason to abandon NSAID use is the risk of heart problems, especially in people with prior coronary disease, as I’ve detailed in past columns. NSAIDs interfere with the production of chemicals in the body called prostaglandins, which can increase the risks for developing heart attacks and strokes. Diclofenac appears to be the NSAID with the greatest risk for causing adverse cardiovascular outcomes. In one study, the 30-day adverse event rate for major cardiovascular events among people who started taking diclofenac increased by 50 percent compared with those who didn’t take the drug, by 20 percent compared with acetaminophen (Tylenol) or ibuprofen users, and by 30 percent compared with naproxen users.

A recent article emphasized that an increasing proportion of people in the U.S. hospitalized for their first heart attacks are younger than 55 years, with the greatest increase in young women. The article listed seven most common sex-specific associations of demographic, clinical, and psychosocial risk factors associated with the first heart attack. These associations accounted for 85 percent of the risk, but drugs such as NSAIDs were not included. The seven risk factors were diabetes, depression, high blood pressure, smoking, family history of early heart attack, low household income, and elevated cholesterol. Interestingly, high blood pressure, depression, diabetes, current smoking, and family history of diabetes had stronger associations with heart attacks in young women, whereas elevated cholesterol had a stronger association in young men.

It does not appear that the study specifically investigated whether NSAIDS were used. Considering the young age of the participants, they might not likely be users. Nevertheless, whether NSAIDs are a major or minor contributor to heart attack risk, they are an established cardiovascular risk.

Coupled with the information from the first study noted above, the evidence is sufficiently compelling to make me seek treatments other than NSAIDs for my aches and pains. In fact, I’ve just tossed out my bottle.

The main goal of treatment is to reduce pain, improve mobility, and help one return to daily activities without discomfort. Because individuals respond to pain differently, management needs to be tailored for a specific person, depending on symptoms and underlying health conditions. Acetaminophen (Tylenol) is a good start for most people. It is most important to remember that all medication carries some risk and should be taken in the lowest effective dose possible and for the shortest time necessary to achieve the desired effect.

The acronym RICE contains the important elements to deal with an acute injury: rest (of the injured part), ice, compression, and elevation.

Non-drug approaches to chronic problems include electrical stimulation to reduce pain with mild electric shocks to the skin that affect the nerves distributing the pain sensation, nerve block by injection or surgery to eliminate transmission of the pain signals, and acupuncture to modify the nerve impulses.

Some lifestyle remedies that help ease chronic pain include physical therapy, tai chi, yoga, art and music therapy, massage, and meditation. For some, stress reduction by getting enough sleep and exercising regularly can help.

Isolation can cause one to focus on the pain and worsen its effects. Friends, family, and support groups can be helpful and offer comfort during difficult times by providing needed support. Participating in enjoyable activities and socializing with family and friends can improve outlook in dealing with the pain.

Opioid problems have been well publicized, so before going that route, I would advise chronic pain sufferers to seek out health care professionals who are experts in pain management. Consider contacting the American Chronic Pain Association for help.

Featured image: Shutterstock

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