Pain Medication: Risks and Alternatives

Paul L. Reller L.Ac. / Last Updated: August 03, 2017


In the last decade or so we have seen nonsteroidal anti-inflammatory medications taken off the market (re: the Vioxx scandal), enormous fines for off-label drug promotions of Cox-2 inhibitors, black box warnings of risks for NSAIDS, the creation of legislation to curb chronic overuse of narcotic pain medication due to a large number of overdose deaths and injury in common medical use (over 15,000 overdose deaths yearly in the U.S. from opioid pain relievers alone, and over 22,000 medication related deaths in 2010, according to the U.S. CDC - and then an explosive surge in these deaths since 2010, with a dramatic rise in prescription drug overdose deaths to nearly 44,000 per year in 2013), and now sharp restrictions by the U.S. FDA of common pain medication use due to the large number of deaths and injury attributed to acetaminophen (paracetamol) poisoning, mostly from chronic use of narcotic pain relievers containing acetaminophen and high dosage over-the-counter drugs. In addition, the alarm bells have gone off concerning the high incidence of harm from concurrent use of ibuprofen with acetaminophen, although dealing with this common problem is difficult, as the kidney and liver damage is insidious and gradual. We are still trying to formulate successful guidelines to prevent the large number of deaths and injury from overuse of aspirin and other NSAIDS concerning gastric ulcers and gastrointestinal bleeding, and since 1999 large cohort population studies have finally confirmed that not only GI bleeding, but an array of health problems in the gastrointestinal tract can be clearly linked to chronic use of NSAIDS, but not aspirin, and the risk of eventual mortality associated with this common reliance on pain medication is surprisingly high (see studies and warnings in Additional Information).

For decades the only published studies of chronic use of common pain relieving medication were designed to prove health benefits, ignoring health risks. We have seen clinical evidence since these drugs were created in the 19th century that chronic use came with considerable risk of gastrointestinal bleeding and complications that resulted in many deaths each year, yet downplayed this threat. More and more scientific studies are finally showing us that our common pain relievers provide limited short term relief and come with considerable adverse health effects with chronic use. Overlooked in this array of common risks of chronic NSAID use was the mounting evidence that these non-steroidal anti-inflammatories (NSAIDs) pose considerable cardiovascular risk, even with short-term use in a healthy individual, hence stronger black box warnings were issued in 2015. By 2016, we are seeing studies that show that the common prescription of NSAIDs for tendinitis has largely been a mistake, as biopsies show that a large majority of cases of tendon strain and pain do not involve inflammatory cytokines, and the NSAIDS inhibit prostaglandins that are involved in the creation of collagen when tendons are healing, in effect slowing healing. Pain relief from a pill that counters inflammation when there is no inflammation may be a 'placebo effect', and could be slowing the healing in tendon injuries.

All of this information makes patients with chronic pain dizzy, and anxious, but the over-prescription of anti-anxiety benzodiazepines is now also causing an alarming number of yearly overdose deaths, as well as a unique rebound withdrawal addiction problem. Proper short term use of pain medications to allow increased therapeutic activity to actually treat the various causes of pain is safe and sensible, but the enormous overuse and abuse we are seeing now is not. The obvious solution to this problem is to finally integrate safe conservative healthcare for pain and related problems with utilization of the specialty of Traditional Chinese Medicine (CIM/TCM), particularly the holistic clinical practice of combining soft tissue physiotherapy with acupuncture and herbal and nutrient medicine, all delivered in the same treatment.

An article in the New York Times Health section of June 14, 2016, entitled An ER Kicks the Habit of Opioids for Pain, describes the approach to pain now taken in the Emergency Room (ER) of St. Joseph's Regional Medical Center in New York, associated with the New York University School of Medicine. Here, more conservative complementary therapies are tried when possible, with trigger point needling injections, localized nerve blocks guided by ultrasound, laughing gas, soothing music, and even energetic healing. For many patients, the use of narcotic pain medication in the ER presents considerable health risks with brain function and constipation, as well as the threat of narcotic addiction. If the pain can be relieved with Complementary and Integrative Medicine (CIM), Medical Doctors are now trying these methods, even in the ER. One reason is that more than 1,150 patients per day are seen in U.S. Emergency Rooms for overdose or other emergency health problems associated with opioids, and the CDC stated that in 2014, records showed at least 14,838 deaths related to prescribed opioid pain medication, with many more related to a combination of these medications and heroin. At St. Joseph's nurse practitioners are receiving degrees from TCM Medical Colleges to practice acupuncture in the ER setting, and treatment techniques considered to be ridiculous quack medicine not long ago are being integrated into care.

Added to all of this data on pain medication hazard was the 2015 meta-review from the University of Sydney School of Medicine, published in the British Medical Journal (BMJ), which showed at this late date that acetaminophen, added in high dosage to almost all narcotic pain medications, and heavily prescribed for pain for decades, does not relieve low back and neck pain any better than placebo, and shows only a small benefit over placebo for oestoarthritic hip and knee pain (see study links in Additional Information). This information comes only after decades of overuse of acetaminophen that finally resulted in U.S. FDA mandates to curb its use and dosage. Decades of advice from standard medicine to avoid conservative care and restorative medicine, with a wide array of benefits, in the form of acupuncture, electroacupuncture, soft tissue physiotherapy, and herbal and nutrient medicine, because it was not yet supported by large randomized controlled human clinical trials, whose study design was manipulated to make this difficult, and which was not required to support all other manual therapies, was apparently very cynical when looking at this absurd history of pain medication protocol.The only problem for patients is that, once again, the situation is so complex that most people really don't want to think about it.

Wait, this scenario of deceit and duplicity in the guidelines for pain management get even worse. In 2016, experts at the University of Sydney School of Medicine, in Australia, led by Dr. Andrew J. McLachlan, released a definitive meta-review of 20 high quality randomized controlled human clinical trials of narcotic pain medication for low back pain and found that a wide variety of opiates studied did not outperform NSAIDs and aspirin, providing only mild relief, below what the researchers deemed clinically relevant. To see this meta-review, just click here: . These researchers noted that a more holistic protocol involving targeted stretch and exercise would be more effective. Of course, CIM/TCM, now well documented to provide significant relief and improved function, which the narcotic pain medication failed to do, and in fact usually decreased function with chronic use, was not mentioned, again, yes, again. It seems that millions and millions of patients with subacute and chronic pain were harmed by advice and guidelines to just take pain medications that did more harm than good, and perhaps were continued in the case of opiate narcotic pain medication more due to the addiction than the pain relief.

What we are left with is the fact that prescription pain medications now comprise the largest category of drug abuse in the U.S., much of which comes from teenage use of parent's pain relieving narcotic medication, and the illicit diverting of pharmaceuticals to the street market, via burglaries, prescription forgeries, employee theft, and "doctor shopping", as well as illegitimate prescribing, and diverting of pharmaceutical "samples" by drug representatives. By 2012, many states have initiated programs to educate and control prescription drug abuse, and the problem has become so severe that all Medical Doctors are being required to suspect all patients of potentially acquiring narcotic pain medication for the purpose of selling it. For example, the Attorney General of Kentucky, Jack Conway, stated that 3 people per day die of prescription drug overdose in Kentucky, as he kicked off the Keep Kentucky Kids Safe awareness program. Added to these types of harm is the increased risk of birth defects noted in patients that were taking narcotic pain medication preceding pregnancy and during the first trimester (see the link to the study summary in Additional Information). The United States Centers for Disease Control and Prevention (CDC) states that the number of yearly deaths from "poisoning" exceeded those attributed to firearm deaths for the first time in 2005, and that at least 91 percent of these "poisonings" were attributed to drugs, the vast majority to pharmaceutical drugs, or unintentional deaths from pharmaceutical pain medications and combinations of prescribed drugs. Even heroin overdose deaths, rising alarmingly in 2013, were reported to be occurring more often because dealers were adding the pharmaceutical narcotic Fentanyl to the heroin, and Fentanyl is especially dangerous for unintentional overdose deaths. It seems that the regulation of prescription opioid medication is very lax. Patients and doctors are now looking more seriously at an alternative to the enormous reliance on pain relieving medication, and Complementary and Integrative Medicine (CIM/TCM) is supplying healthy and safe alternatives to controlling pain with drugs, including acupuncture, physiotherapies, herbal and nutrient medicine, and patient instruction in therapeutic activities.

While treatment of pain in Complementary and Integrative Medicine (CIM) may not be as easy as taking a pill, the effects may be much more beneficial in the long term. TCM, or the medical specialty of Traditional Chinese Medicine, commonly just referred to as 'acupuncture', provides patients with a comprehensive possibility of treatments to not only relieve pain, but to correct the underlying causes of the pain, and promote better tissue healing. The TCM specialty also offers the potential of real neurological modulation of pain hypersensitivity and syndromes of neuroimmuno-psychopathologies, such as fibromyalgia, as well as correction of underlying neurohormonal problems that inhibit proper tissue maintenance and repair. Numerous scientific studies now validate this comprehensive treatment protocol of acupuncture, electroacupuncture, soft tissue physiotherapy (Tui na), and herbal nutrient medicine, for relief of symptoms, improvement in function and quality of life, and for cost of care benefits, with virtually no side effects except for better overall health. The U.S. CDC reported that the yearly cost of prescription opioid abuse in the United States in 2007 was estimated at $55.7 billion, with about half related to increased healthcare costs that drive up insurance rates for us all, and are the biggest contributors to the federal budget deficit, affecting us all eventually in higher taxes. The other half of this $55.7 billion yearly cost is related to time off work and decreased productivity, and to increased law enforcement costs, which also hurt all of our pocketbooks indirectly. These figures will surely be much higher when finally analyzed for 2016, as this societal cost has ballooned, and the U.S. CDC stated that by 2010, opioid pain medications were involved in at least 60 percent of all recorded drug overdose deaths. The culture and business of pain management and treatment of health problems with pain can no longer be viewed with blinders on. The investment in utilization of safe and effective care with CIM/TCM would reduce these alarming costs dramatically, and the only side effect would be better overall health and more health awareness by the public. We must start looking at the big picture and ignore industry propaganda.

Studies in recent years show that patients utilizing a multidisciplinary treatment approach, instead of opioid pain medication, had a chance of recovery from a chronic pain syndrome almost 4 times as high, with a significantly greater health-related quality of life. A renowned health outcomes researcher at Memorial Sloan-Kettering in New York, Dr. Andrew Vickers, published his meta-review of the scientific study of acupuncture to treat chronic pain in a 2012 issue of the Annals of Internal Medicine, and declared that there is no longer any scientific doubt of efficacy for acupuncture. In 2010, the U.S. Army Surgeon General, Lt. Gen. Eric B. Schoomaker, announced in a press conference that acupuncture has met the highest standards of proof of scientific efficacy and was now a valuable tool in treating soldiers with chronic pain and reducing or eliminating chronic dependency on pain medication, an enormous health problem for soldiers and veterans. These strong endorsements do not really portray the complete treatment protocol for musculoskeletal injury and disease, though, as the specialty of Traditional Chinese Medicine offers an array of symbiotic therapeutic protocols that greatly add to the efficacy of acupuncture needling alone. The integration of physicians who actually apply hands-on therapy to treat pain, not just prescribe these pain medications, is long overdue. Herbal medicine, too, is finally being seriously studied and these studies finally printed in scientific journals, with decades of bias and misinformation finally being reversed. For instance, in 2014, the most commonly prescribed herbal medicine for pain in TCM practice, from the herb Yan hu suo, or Corydalis, was seriously studied at the University of California at Irvine, in the U.S.A. and a chemical compound from the herb, Dehydrocorybulbine (DHCB), was proven to relieve both inflammatory pain and nerve-related pain, a type of pain that no standard pain medication is able to successfully treat. These researchers also noted no significant adverse effects, and no tolerance tot he herbal medication over time, and the scientific journal Current Biology printed the study in the January 20, 2016 issue. To see a review of this study, click here: . This is just one of many such studies that will provide proof of TCM herbal medicine in treating pain successfully. Of course, the effects of pain relief from herbal medicine are not immediate, but occur over continued use, and the best use of herbal medicine for pain relief is in the integrated protocol with herbal formulas, topical herbal medicines, acupuncture stimulation, and actual deep tissue, or soft tissue, mobilization and physiotherapy (Tui na).

TCM physicians, or Licensed Acupuncturists and herbalists, may utilize acupuncture stimulation, electrical stimulation, diathermy, herbal and nutrient medicine, mind-body medicine with cognitive and behavioral modification, and even direct soft tissue physiotherapies, called Tui na in China, which encompasses myofascial release, active release technique, neuromuscular reeducation, and a variety of techniques of tissue mobilization, all in the same treatment session. Such time-intensive and comprehensive approaches will achieve pain relief and actual tissue healing in a relatively short time, and should be utilized in short frequent course of acupuncture and phyisotherapy, with more prolonged step-by-step approaches with herbal medicine and therapeutic activities. Even newly researched techniques such as low intensity laser therapy are included in the scope of practice of the License of Acupuncture, as well as various types of electrical stimulation. Acupuncture, in recent years, has been heavily researched to discover how it relieves pain. Despite the problems of gauging the effects of acupuncture on humans with a randomized comparison to placebo (obviously there is no such thing as a true sham placebo when actually sticking a person with a needle and manipulating it effectively), almost all human clinical trials of acupuncture for the relief of pain show significant pain-relieving effects. Since the "placebo effect" is part of the real effect in acupuncture, stimulating the mind-body mechanisms to change pain perception, the question of whether acupuncture only works via this "placebo effect" has been much publicized, but is not a real issue. Research in recent years has proven that there are beneficial types of "placebo effect" that result in measurable improvement, and TCM has adopted this mind-body effect for centuries, although most of the effects in TCM practice are direct and practical, not the result of a placebo. We have known that levels of circulating endorphins and dynorphins, which are opioid neurotransmitters that our bodies use to moderate pain signals, significantly rise with acupuncture stimulation, and that a course of repeated acupuncture stimulates a long lasting rise in these chemical mediators. The mechanisms of pain relief, and the objective scientific elucidation of this "placebo effect", though, have been more thoroughly revealed in the last decade with sound research at the most prestigious universities in the United States, perhaps due to the amount of skepticism shown in standard medicine. There is no single way that TCM relieves pain, but rather many ways.

In 2009, researchers at the University of Michigan Chronic Pain and Fatigue Research Center used three forms of brain imaging to assess the objective effects of acupuncture stimulation on the areas of the brain that perceive and modulate the pain signals, especially in chronic pain, which is often heavily subjective and tied to memory and emotion. This study, published in the medical journal Journal of NeuroImage in September of 2009, found that simple acupuncture needle stimulation alone increased the binding ability of mu-opioid receptors (MOR) in regions of the brain that process and dampen pain signals - specifically the cingulate, insula, caudate, thalamus and amygdala (see the article entitled Brain Health and Function on this website to learn more). "The increased binding availability of these receptors was associated with reductions in pain", stated the head researcher, Dr. Richard E Harris, Ph.D., an assistant professor of anethesiology at the University of Michigan School of Medicine. The human study participants in this initial clinical trial were diagnosed with fibromyalgia. The researchers stated that the implications were that acupuncture needle stimulation alone may not only relieve chronic pain, but also increase the effects of narcotic pain relievers, thus reducing the dosage needs. When combining this needle stimulation with the other TCM modalities, especially the direct soft tissue physiotherapies to correct the causative problems, and the use of herbal and nutrient medicines and mind-body medicine to improve physiological function, decrease inflammatory dysfunction, balance the neurohormonal responses, and effect other circulatory and tissue healing effects, Complementary Medicine shows that this holistic approach is not only scientifically sound, but should be the preferred alternative to chronic use of pain medication for any patient that is actually looking to get well and not just 'manage' their pain.

In the September 10, 2012 issue of the esteemed medical journal Archives of Internal Medicine, the renowned health outcomes researcher Andrew Vickers of Memorial Sloan-Kettering in New York released his meta-review of current scientific research on acupuncture and the treatment of chronic pain. In this meta-review Dr. Vickers and colleagues limited research data to only the highest-quality human clinical trials to deflect the historic criticisms of acupuncture research. This review, from over 18,000 patients in 29 high-quality clinical trials, provided proof that acupuncture treatment for chronic pain significantly outperforms so-called sham or placebo acupuncture, and more importantly, outperforms standard treatment by even greater measures. Dr. Vickers was quoted as stating: "Our findings provide the most robust evidence to date that doctors are justified in making referrals to acupuncture for their patients with chronic pain. I hope that our findings help inform future clinical and policy decisions for acupuncture."

The medical practice that we call acupuncture involves much more than just the needle stimulation, though. Direct soft tissue therapies, along with herbal and nutrient medicines, help to heal the injured and degenerated tissues that are the cause of most pain. To actually treat this underlying cause is the most practical way of getting rid of the pain permanently. Merely medicating only perpetuates the pain syndrome, and the alarming rise in the number of deaths and adverse health effects attributed to pain medications should be a wake-up call to both physicians and patients. In 2011, the U.S. Centers for Disease Control and Prevention (CDC) released a report that found more than a tripling of the number of yearly deaths attributed to narcotic pain reliever use over a ten year period. Almost of all of these narcotic overdose deaths occurred with use of Hydrocodone (Vicodan), Oxycodone (Oxycontin), Oxymorphone (Opana), and Methodone (especially when prescribed for pain). These prescribed pain medications led to the death of more than 15,000 patients in 2008 in the United States, a steady rise from 4000 overdose deaths in 1999, and by 2012, the number of narcotic pain medication overdose deaths had increased substantially for 11 years in a row. The CDC report shows that nearly 5 percent of Americans say that they have abused narcotic pain medications in the past year, and so many narcotic pain prescriptions are now written that the total would give every American a one month supply, says Dr. Thomas Frieden, director of the CDC in Atlanta, which issued this report. Talk about drug pushers. Dr. Frieden describes this as an epidemic, and told an Associated Press reporter that, in his opinion, doctors should limit prescriptions, giving only enough for acute pain episodes, and look for alternative treatments. The time has come for medical doctors to utilize more conservative therapies to correct the problem of pain, and the skilled Licensed Acupuncturist, along with Chiropractors, Physical Therapists, and Osteopathic doctors can provide this conservative care. The patient population as well as the general public, and public health authorities, need to demand a change. When totaling the number of deaths attributed to the various types of pain medication, narcotic, non-steroidal anti-inflammatories (NSAIDS), acetaminophen, and steroidal medications, the yearly number of unnecessary deaths is now astounding.