Pain Relief Proves to Be Risky Business

By William H. Thomas, M.D.

January 2005 - You’ve read the articles in the newspaper, heard the reports on television and the radio: Vioxx has been pulled from the market, and several other commonly used pain relievers also are being scrutinized for an increased risk of heart attack and stroke. For the many people who have used a particular pain reliever to treat chronic joint and back pain, the list of safe alternatives seems to be fast running out.

But what you likely haven’t heard is how these drugs evolved—and how previous generations of pain relievers may still work just as well, especially when combined with practical risk-reduction strategies.

Be sure to consult with your doctor before changing the dose or type of pain reliever that you use. Explain which pain reliever you’ve been taking—for how long, for what kind of pain, and what happens when you stop. Also, make sure your doctor knows about other prescription and over-the-counter medicines that you take. It’s important to review any adverse reactions that you might have had in the past to other pain relievers.

Discuss these five risk-reducing options with your doctor to determine if they’re right for you:

Reduce the dose. Whether you have been taking a prescription drug such as Celebrex or Bextra, or an over-the-counter pain reliever such as Motrin, Advil or Aleve, ask your doctor if a lower dose may work for you. Remember, the higher the dose, the higher the risk.

Take a holiday. Because steady long-term use creates more risk than short-term intermittent use, it is best to cut back on these medications whenever possible. Indeed, many patients are actually able to take "drug holidays" that give the body a vacation from a particular medication. Consult with your doctor to determine how often and how long to take such vacations—if at all.

Consider a different medication. Established non-steroidal anti-inflammatory drugs—such as Aleve (see box to right), Advil and Motrin—are just as effective as the newer prescription painkillers making news these days. Their main drawback is the risk of stomach irritation. One way to reduce the risk of gastrointestinal side effects: Your doctor may recommend a stomach-protecting medication such as Prilosec (which is now available over the counter) or Cytotec (which requires a prescription).

Try Tylenol instead. Some patients can avoid anti-inflammatories (and their associated stomach irritation) entirely. Tylenol (acetaminophen) is very well-tolerated and can work as well as prescription medications. It’s a painkiller, not an anti-inflammatory; the amount of inflammation associated with the common form of "wear and tear" arthritis is relatively mild, and that means that Tylenol can sometimes match the success of anti-inflammatory medications. Consult with your doctor about using Tylenol for chronic joint or back pain; the results might surprise you, and the safety record is unmatched.

Go natural. The dietary supplements glucosamine and chondroitin have been used in Europe since the 1980s. When combined, they can reduce inflammation and stimulate cartilage repair. Research shows that they’re at least moderately effective in the treatment of joint pain due to osteoarthritis. Side effects are mild and rare, and no interactions with prescription drugs have been identified, but check with your doctor before adding them to your pain-fighting arsenal. [Note: Supplements are subject to little federal oversight; some products can cause serious and sometimes deadly side effects. Read the May 2003 AARP Bulletin article Strike Three for Dietary Supplements?]

Of course, the best ways to reduce your risk of heart attack and stroke are to quit smoking, maintain a healthy diet, keep your weight in check, exercise regularly and treat high blood pressure. When it comes to chronic joint pain, stretching and the application of heat or ice are vital but often-neglected strategies for minimizing pain and stiffness.

The Story Behind the Story

Anyone who has ever suffered from a toothache can attest to the close connection between inflammation and pain. Millions of Americans live with the pain and limited mobility that result from chronic inflammation. Not very long ago, steroids (such as prednisone and Decadron) were the only medications that could reliably treat acute and chronic inflammation. Unfortunately, steroids are frightfully dangerous drugs. So when a new class of pain- and inflammation-relieving medications came to market, doctors and patients alike hailed these non-steroidal anti-inflammatory drugs (NSAIDs) as wonder drugs.

There was just one problem: Many patients found NSAIDs (such as Motrin, Advil and Aleve) to be "hard on the stomach." Even worse, these medications soon developed a reputation for causing stomach ulcers. Patients using NSAIDs tripled their risk of serious intestinal complications, including hemorrhage and death.

These safety problems sent scientists scurrying back to the laboratory, where they developed a new generation of NSAID pain relievers known as COX-2 inhibitors. They were just as effective as older NSAIDs but offered the bonus of being easier on the stomach. Supported by massive direct-to-consumer advertising campaigns, Vioxx, Celebrex and Bextra became household names.

The success of these expensive new medications was based on the claim that they were substantially safer than the first generation of NSAIDs. However, the current crisis erupted when it became apparent that the risks created by these medications were much greater than many people had believed.

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