MSK Medications Awareness

Qualifier: I am not a pharmacist or GP, so my drug knowledge is limited. That being said, being a primary contact practitioner it is important I have an awareness of the effects and side effects certain medications my clients might be taking. Also, not being 'brought up' with a script book in my back pocket, I am comfortable looking at alternatives and providing these suggestions to my clients. They can then discuss this with the other members of their medical team or do their own research.

I recently had a client present with ongoing low back pain who was consuming 4 pain modifiers (including a patch) and 1 non-steroidal anti-inflammatory (NSAID) - all prescribed. In our practice, there are two common groups of meds being used; NSAIDs (e.g. nurofen, ibuprofen, voltaren) and opioid based medications (e.g. panadeine, panadeine forte, tramadol, endone, oxycontin). These medications have common side effects (e.g. gut reactions or trying to pass a brick with back pain, which isn't exactly comfortable) and these compound with longer term use.

Let's first look at NSAIDs

Generally, these work to block the chemicals (prostaglandins) our body produces in relation to inflammation, and in doing so, reducing associated pain.

Manage Acute Inflammation

E.g. arthritis aggravation, joint strain or trauma. Clinically NSAIDs seem effective on joint conditions, but not from my clinical experience muscle pain or trigger points. Which means that if a client has been taking NSAIDs for a week or two, with little change in symptom presentation, then consider muscular problems.

Preventing post-surgery chronic pain

Research doesn't indicate the approach of using these medications before, during or after surgery to prevent post-surgery pain. See here

Manage Longer Term Inflammation

With any longer term medication use, benefits need to be weighed against side effects - stomach reaction being the most common, but more recently the raised awareness of association with heart attack (35% increased relative risk), stroke, kidney (25% increased sodium retention) and liver damage. See here.

Tendon and bone healing

In regards to chronic tendon pain, inflammation is not generally considered an important part of the process, see here and their role considered minimal. In regards to using NSAIDs in association with bone healing, researchers concluded "clinicians should treat NSAIDs as a risk factor for bone healing impairment". See here. It is noted that a lot of the research uses animal models, and these indicate that bone, ligament and tendon/bone junction healing are impaired in the presence of NSAID compounds. See here.

Okay, what about Opioids?

The name pain killers is over optimistic and we need to communication this to our clients. Pain medications are analgesics or pain modifiers, and only tend to help about 1 person in 4 improve their pain by 50% (or more), compared to a placebo treatment. What this means is when pain medications are given to 4 people, only one of them will get 50% or more relief.

According to the US Centers for Disease Control, the amount of prescription opioids sold in the U.S. nearly quadrupled since 1999, yet there has not been an overall change in the amount of pain that Americans report. Deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone - have more than quadrupled since 1999.

Against a background of high reported potential for serious adverse effects& complications; increased risk of misuse (4* increased rate of consumption see here) abuse, addiction, overdose, and deaths, usage of opioid medication needs to be carefully considered. Not to mention the common side effect of constipation, which when combined with low back pain, well ....

Speaking of low back pain, the most comprehensive reviewof research looking at usage of opioids for this very common clinical presentation, warned about use in both short and long term situations. See for full details

Short Tem

The review concluded that even though opioids are one of the most commonly prescribed medications (along with NSAIDs) there was no research on which to base any decision of usefulness in the short term.

Longer Term

The problem with longer-term use, was that greater quantities and higher dosages were required to gain pain relief. This upward spiral (law of diminishing returns if you're an economist) wasn't sustainable, given the increase in side effects (about 50% participants pull out of research trials) and potential for abuse and addiction.

painHealth has a useful fact sheet on NSAIDs and Analgesics that you can download here.

When considering these medications, individuals need to make informed decisions, balancing the research, the pros and cons and also as part of this process, examining alternative evidence based options. In the second par to this article I will be outlining some alternative options that you could consider when advising your clients about pain and inflammation modification.

Thanks for reading. Love hearing your thoughts in the comments section.