What is the Best Medication to Take for my Back Pain?
I am frequently asked by patients: ‘what drug should I take to ease my back pain?’ My normal response is to avoid taking them if possible, unless you are really finding it a struggle to sleep at night.
One of the most commonly available pain-killers is paracetamol, and, because most people already have some at home, it is often taken in an attempt to ease back pain.
One study reviewed all the published evidence in relation to using paracetamol to treat low back pain (1)
Based on the available evidence they concluded that: ‘paracetamol is ineffective in the treatment of low back pain and provides minimal short-term benefit for people with osteoarthritis.’
The UK National Institute for Health & Care Excellence (NICE) guidelines corroborated this and they no longer recommend paracetamol for back pain treatment.
What Anti-Inflammatory Drug Should I Take for My Back Pain?
The drugs that are most frequently used for treating back pain are the anti-inflammatory group of drugs. For decades, they formed the standard practice in treating back pain.
Because of the opioid crisis, the pharmaceutical industry are looking for alternative treatments for pain. One alternative is the use of non-steroidal anti-inflammatory drugs (NSAIDs). (5)
In the U.S. for example, around 60% of patients with osteoarthritis or chronic low back pain are prescribed NSAIDs.
In the UK, the National (NICE) guidelines recommend anti-inflammatories (NSAIDs) as the first choice for treating back pain & sciatica.
Anti-inflammatory drugs (NSAIDs) are commonly used for pain management. Common examples of include:
- Ibuprofen
- Diclofenac
- Celecoxib
The logic behind the use of anti-inflammatories is that decreasing inflammation will lead to a decrease in pain and speed up recovery. A common misconception amongst patients is that their back pain is caused by local inflammation. In the vast majority of back pain that I treat there is no evidence of inflammation in the site of back pain.
Even in cases where inflammation is present, the question is:
Is inflammation harmful?
Does blocking inflammation improve healing?
How much inflammation is too much?
How long should I take anti-inflammatories for, if at all?
Should I take anti-inflammatories if I have a fracture?
It has been recognised for a long time that taking NSAIDs decreases bone healing and increase the rates of non-union of bones. Because of this, they are generally avoided after orthopaedic surgery.
Previous research in animals also suggests that anti-inflammatory drugs (NSAIDs) may delay wound healing (4,6).
The anti-inflammatories block prostaglandins which have been shown to play an important role in bone repair, which includes differentiation of osteoblast and osteoclast precursor cells (6)
If they block wound and bone healing, is this an indication that they may have a similar impact when it comes to spinal pain?
What is the Evidence for Anti-Inflammatories in Helping Back Pain?
Mancado & colleagues reviewed the available data on anti-inflammatory drugs for treating spinal pain. They included 35 high quality studies (known as randomised controlled trials). (3)
From analysing all the available research, they concluded that anti-inflammatories (NSAIDs) are effective in treating spinal pain; however, they are no more effective than using a placebo
They reported that 6 participants needed to be treated with NSAIDs, for one additional participant to achieve clinically important pain reduction.
Can Blocking Inflammation Lead to Long-Term Back Pain?
A recent study attempted to answer some of these questions by testing for inflammatory markers in blood samples from 98 patients with recent onset low back pain (2)
At follow-up 3 months later, when testing blood samples for inflammation, they found that participants whose pain had gone at 3 months demonstrated more inflammation on initial testing. Inflammation was indicated by the presence of a higher number of immune cells known as neutrophils.
In the group with persistent pain, there was no increase in inflammatory cells measured on initial testing.
Neutrophils are a type of immune cell that helps to fight infection and dominate in the the early stages of injury.
Here, the researchers found that blocking neutrophils in mice prolonged the pain up to ten times the normal duration. In mice, treating the pain with steroid or nonsteroidal anti-inflammatory drugs (NSAID) like diclofenac led to prolonged pain, despite helping to decrease pain in the short term. The mice were less sensitive to touch in the initial phase.
If the scientists administered neutrophils, then this prolonging of pain was reversed, showing that these immune cells are vital for recovery from back pain.
So, the presumption that decreasing swelling aids recovery needs to be re-evaluated in light of these findings.
As part of the study, they examined data of 500,000 people from the United Kingdom Biobank, a database of medical information. They found those taking anti-inflammatory drugs to treat their pain were much more likely to have pain two to ten years later.
They also found that taking painkillers, such as Tylenol were less likely to experience chronic pain compared to those who took anti-inflammatory medication.
Benefit & Risk From Taking Anti-Inflammatories
At present, there are no pain-killers that provide clinically important effects for spinal pain over placebo (3)
Even after all this is considered, ‘NSAIDs increased the risk of gastrointestinal reactions by 2.5 times’, contributing to 18,000 gastric bleeds each year in the UK, & contributing to over 2,000 deaths.
References:
- Machado GC, Maher CG, Ferreira PH, Pinheiro MB, Lin CW, Day RO, McLachlan AJ, Ferreira ML. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015 Mar 31;350:h1225. doi: 10.1136/bmj.h1225. PMID: 25828856; PMCID: PMC4381278.
- Parisien M, Lima LV, Dagostino C, El-Hachem N, Drury GL, Grant AV, Huising J, Verma V, Meloto CB, Silva JR, Dutra GGS, Markova T, Dang H, Tessier PA, Slade GD, Nackley AG, Ghasemlou N, Mogil JS, Allegri M, Diatchenko L. Acute inflammatory response via neutrophil activation protects against the development of chronic pain. Sci Transl Med. 2022 May 11;14(644):eabj9954. doi: 10.1126/scitranslmed.abj9954. Epub 2022 May 11. PMID: 35544595.
- MachadoGC, Maher CG, Ferreira PH, et al. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Annals of the Rheumatic Diseases 2017;76:1269-1278.
- Nagano A, Arioka M, Takahashi-Yanaga F, Matsuzaki E, Sasaguri T. Celecoxib inhibits osteoblast maturation by suppressing the expression of Wnt target genes. J Pharmacol Sci. 2017;133(1):18–24.
- Zhao-Fleming, H., Hand, A., Zhang, K. et al.Effect of non-steroidal anti-inflammatory drugs on post-surgical complications against the backdrop of the opioid crisis. Burn Trauma 6, 25 (2018). https://doi.org/10.1186/s41038-018-0128-x
- Jeffcoach DR, Sams VG, Lawson CM, Enderson BL, Smith ST, Kline H, et al. Nonsteroidal anti-inflammatory drugs’ impact on nonunion and infection rates in long-bone fractures. J Traum Acute Care Surg. 2014;76(3):779–83.
