Two new studies published in the Annals of Internal Medicine, and the Journal of Pain have both raised questions about the safety of opioids or narcotics for treating back pain. There was some reporting on these studies in the media which left many of my viewers and patients confused and worried about their medications.
First, a little background…
There are several ‘flavors’ of pain medications:
At one end of the spectrum you have over-the-counter analgesics, such as tylenol, which help mild to moderate pain. These medications are relatively safe when taken at the prescribed doses, but can cause liver issues if taken in too much quantity.
Next in line are the anti-inflammatory medications, or NSAIDs- the most common one, Ibuprofen is the generic name for the active ingredient in Motrin or Advil. There are some others such as Alleve, or the prescription drug Voltaren- but they all essentially work in the same way- first as an anti-inflammatory agent, and second as an analgesic medication. These too are relatively safe medications for most people if taken with food at the appropriate dosage. They can present issues for people with kidney disease or gastric problems, so their use should be monitored carefully if taken for anything longer than a couple of days.
There is a subset of NSAIDs known as COX2 inhibitors, which include medications like Celebrex, as well as the discontinued drugs Vioxx and Bextra- that also worked on essentially the same pathway as the other NSAIDs, but were designed to be safer for individuals with gastric problems.
Next, come the non-narcotic pain medications, such as Ultram or Tramadol. These medications are strictly for pain, and offer no anti-inflammatory effect. They can make the user tired, but are claimed to have a lower abuse potential (The likelihood of causing addiction.)
At the far end of the spectrum are the Narcotic medications, which in their own group offer a broad range of strengths. These medications all have some degree of abuse potential if not monitored properly, and come with side effects ranging from dizziness and fatigue to constipation. These are the drugs which offer the greatest amounts of pain relief, and were the subject of the two studies I mentioned above.
The two studies focused on the addictive properties of these medications, and raised questions about their safety- Were these medications necessary? Did they become addictive? Did they cause other side effects such as depression- or at worst, a propensity for suicide?
It is important to consider the role of pain medications in the first place when you address questions like these. Keep in mind, neither study advocated discontinuing the use of narcotics- they both underscored the need for attention on both the part of the prescriber and the prescribee…
When I evaluate a patient for back pain, I will ask them to subjectively rate their pain on a scale from 1-10, and if there is more than one area of pain, I use a subjective pain analysis, which allows patients to provide me with their pain levels on a ‘map’ of their bodies. I then ask questions about their activities of daily living- work, getting dressed, etc.. It is based upon the answers to these questions in conjunction with my own physical examination of the patient that I select a pain medication.
If I were to select a narcotic agent, Percocet for example- I would provide my patient with an appropriate quantity to control their pain until there was a reasonable time interval to re-evaluate them, and that interval would be based upon clinical considerations- and varies from patient to patient.
There are a few situations where these heavy duty medications are indicated for long periods of time, but in most circumstances, my goal is to be able address the cause of their pain, and then progressively decrease the strength of their medication.
In my clinical experience, treating literally thousands of patients over 15 years- these medications are safe when these considerations are taken. Physicians need to be in communication with the patients on narcotic pain meds, and must establish definitive goals for their pain management. In this context, the medications should be considered safe. Patients run into problems when they take higher than prescribed dosages, or communication between the patient and doctor break down- and they stay on the medications longer than they should.
Thanks again for all of the emails- look for a fitness challenge update tomorrow!
Be well,
-Andy
You never know what's on the other side of the door…
