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Are painkillers effective for back pain?

A recent study[1] suggests that popular painkillers, such as aspirin and ibuprofen, are generally useless when it comes to relieving back pain – and in many cases, they can cause more harm than good, according to the review published in the Annals of the Rheumatic Diseases Journal. 

The study revealed that one in six patients treated with non-steroidal anti-inflammatory drugs achieved any significant reduction in pain.  Furthermore, those taking the pills were 2.5 times more likely to suffer from gastrointestinal problems, such as stomach ulcers and bleeding.

Consultant Spinal Surgeon, Mr Bob Chatterjee, and advisor to the NHS Choices website on the treatment of back pain says, “The biggest problem in addressing this question, is what do we mean by back pain?  For example, back pain can be caused by a muscle strain, a slipped disc, wear and tear malalignment of the spine, trauma, cancer, arthritis just to name a few.

Mr Chatterjee also based at Highgate Private Hospital and Harley Street Spine continues, “Interestingly, the National Institute for Clinical Excellence (NICE) has recently updated its guidelines at the end of last year, regarding the treatment of low back pain, and I think it reflects some of what this study is saying.”

We asked Mr Bob Chatterjee his views on the study, and how back pain sufferers should view the findings from the study considering recent news: -

 

1) Do you think that anti-inflammatory non-steroid drug/painkillers provide some relief when it comes to back pain?

I think that they do, although I agree they aren't the most effective. I would agree that paracetamol alone should not be taken for back pain. The NICE guidance is that non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, should be used as a first line, and paracetamol can be added to that. If this isn't strong enough or you aren't able to take NSAIDs, then a weak opioid (morphine-based) drug, such as codeine, can be taken safely with paracetamol. Co-codamol is available over the counter, but stronger varieties will require a prescription from your GP.

 

2) Do you feel that such painkillers can do more harm than good, and why?

In some instances, that may be true, however, not for most cases. The important thing is that you take advice before starting drug treatment. Various sources of advice are available from your GP, pharmacist and the NHS Choices website, to name a few. I think the risk of doing more harm than good is usually from the side effects of the drugs, and being armed with good advice and knowing what to look out for would obviate most causes of harm. NSAIDs aren't suitable for everyone and those who suffer from asthma or have an ongoing history of ulcers in the stomach, can't take it. Also, remember never to take them on an empty stomach, and if you start to get symptoms of acidity in the stomach, an upset stomach, nausea, or even bleeding from the stomach, you should stop taking them and consult your GP.

 

3) Are there any other medical drugs that you feel may be of benefit to back pain?

Other varieties of drugs can be taken after consultation with your GP. Muscle relaxants such as Diazepam can help. These drugs were originally used to treat anxiety, but in different doses, they help to relax the muscle and alleviate the pain deriving from a muscle spasm in the back and buttock. If you have pain in your leg, hip or buttocks (sciatica), your doctor may prescribe a stronger painkiller.

These include:

  • some types of antidepressant, such as amitriptyline and duloxetine – these medications were originally designed to treat depression, but they have since been found to help relieve nerve pain
  • anticonvulsants, such as gabapentin and pregabalin – these medications were originally designed to treat epilepsy, but they can also be useful for treating nerve pain

These medications aren't suitable for everyone, particularly when used in the long term, so it's important to discuss all available options with your GP. Some of these medications can also cause significant side effects in some people.

 

4) What steps can patient sufferers of back pain do to ensure they are receiving the right treatment pathway?

If you have very severe symptoms, such as progressive muscle weakness, altered bladder or bowel function, or numbness around the genitals or anus, these are danger signs and you should consult your GP immediately – you may require surgery.

Although we have focussed on pharmaceutical treatment of back pain, this should be only one facet of the way we manage back pain. Prevention is better than treatment, but if you have on-going back problems, painkillers should be used really to settle your symptoms to allow you to do your stretches and exercise. I often suggest enlisting the help of a therapist. I regularly work with physiotherapists, osteopaths, chiropractors, acupuncturists, massage therapists, just to name a few. Different treatments work for different people, so there is no ‘one answer’ for everybody. Find a good therapist of whichever denomination, perhaps through a recommendation, and they will be able to advise you on the sorts of exercises to do. We also find Pilates and some forms of yoga quite helpful. Generally, your back symptoms should settle within 2-4 months. If it hasn't, then I would recommend you see a Spinal Surgeon. It's important to know that, as a Spinal Surgeon, we only operate as a last resort. For 90% of the patients I see, I don't recommend an operation. I spend most of my time investigating and scanning to make sure I have the correct diagnosis and usually then liaise with their therapist or refer them to one to help focus treatment on the areas that I've identified. If this fails then, the other options are injections and surgery.

Epidural injections consist of water, local anaesthetic and corticosteroids, which are an anti-inflammatory medicine. They may be injected into your lower back to help reduce inflammation and pain if you have severe pain due to sciatica. These injections may help relieve pain in the short term, but their effect tends to wear off over time (around 3 months). The reason to do them is not to cure your problem (because they won't), but to ease your pain much more effectively than any combination of painkillers, which then allows you to do your exercises and rehabilitation much more effectively, thereby speeding up recovery. Effectively, it creates a window of opportunity to allow your body to heal whilst your symptoms are much more manageable.

Whether surgery is required is ultimately dependent on the precise diagnosis, and you would be advised to see a Spinal Surgeon to discuss this. However, a few principles are that, generally, surgery is a last resort unless there is impending paralysis and loss of bowel or bladder control. If speed to recovery is critical (e.g. professional sportspersons) there may be some advantage in going down the surgical route. Otherwise, the only situations in which we tend to operate are where nonoperative management has failed and/or there is a persisting weakness in the muscles. We normally expect most back conditions to improve over 2-4 months, so if by this stage things weren’t improving, we would advise seeking specialist advice for possible MRI investigation and clinical assessment.

 

 

[1] http://ard.bmj.com/content/early/2017/01/20/annrheumdis-2016-210597.short?q=w_ard_ahead_sidetab

Date: 01/05/2018
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