Pain Medication: Risks and Alternatives

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

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Why NSAIDS, such as aspirin and ibuprofen, have inherent risks and adverse side effects with long-term use

NSAIDS, or non-steroidal anti-inflammatory medications, comprise a large list of common pain medications. Aspirin was the first modern pharmaceutical drug synthesized and heavily marketed. It is an alteration of an herbal chemical, salicylic acid (salicin), most commonly derived in Europe from the bark of the white willow tree (salix is Latin for willow tree). In the 1800s, a medicinal extract of white willow bark was frequently used to treat pain and inflammation. Salicylic acid functions as a plant hormone, and is found in a variety of Chinese medicinal herbs, such as ginseng (Ren shen), and Isatis (Da qing ye). Salicylates are a related class of herbal chemicals found in such Chinese pain relieving herbs as Yan hu suo (Corydalis) and Dan Shen (Salvia miltiorrhizae). Salicin from white willow bark was isolated and altered to form a quick acting salicylic acid, which became aspirin, the first pharmaceutical NSAID. Obviously, herbal medicine, the source of these pain relieving drugs, is effective for pain relief and inflammatory modulation, although the herbal medications will not work as fast. To judge the efficacy of these herbal pain relievers, which are now proven to work in scientific studies, one must look at the effects over time.

Another acid, iso-butyl-propanoic acid, commonly called ibuprofen, is now a more common NSAID than even aspirin, marketed under dozens of trade names, such as Advil, Motrin, Nuprin, Naprosen, Emuprofen, etc. These drugs, and the classes of drugs called Naproxen (Aleve, Naprosyn), and COX-2 inhibitors (Vioxx, Celebrex, etc.), all work by inhibiting enzymes that convert arachidonic fatty acids to PGE2 (prostaglandin E2) or PGH2, and to thromboxane A2. In the inflammatory process, our bodies create a number of inflammatory mediators from essential fatty acids, and PGE2 regulates some of the inflammatory processes associated with pain, such as swelling and decreased local circulation. Thromboxane 2 controls platelet aggregation, or the clotting of blood, and an anti-thromboxane 2 effect enhances circulation. Unfortunately, inhibition of PGE2 with aspirin and other NSAIDS also inhibits all prostanoid synthesis, which is an undesirable effect overall. When all prostanoids are inhibited, our inflammatory system, a key aspect of our immune responses, is not able to sufficiently clean up chronic tissue problems, and eventually, such tissues as arterial linings and stomach membranes will suffer. Hence, these NSAIDS create increased ill health and risks with cardiovascular disease and gastrointestinal disease, and may cause or contribute to strokes, heart attacks, bleeding ulcers in the stomach and small intestine, and a host of other problems. While inhibition of PGE2 relieves symptoms of pain and swelling, one of the enzymes inhibited, prostaglandin E synthase, is also involved in glutathione metabolism, and an inhibition of glutathione metabolism may have devastating consequences, since this is our body's main cell detoxifying mechanism (see the article entitled Glutathione Metabolism, restoration and balanceon this website). Chronic overuse of NSAIDS will have a negative effect on the glutathione detox metabolism, which is associated with many difficult chronic diseases.

Inhibition of PGE2 has other consequences as well. PGE2 functions to decrease gastric acid secretion, increase gastric mucosal secretions, contract the uterus, contract gastrointestinal smooth muscle, inhibit lipolysis, and increase autonomic neurotransmitters. The potential adverse effects with long-term excess use of NSAIDS thus include gastric hypofunction, poor digestion, constipation, weight gain, affects on fertility, and numerous symptoms of autonomic dysfunction. Of course, a short course of NSAIDS to relieve pain is harmless and without problems. This is what the drug is intended for. On the other hand, long-term use, excess dosage, and combination with acetaminophen, comprise many adverse effects. The intelligent patient and physician will utilize some more conservative strategy with the treatment of chronic pain, and even with subacute pain, since the use of pain relievers after a short number of days is probably not wise. When pain relief is required, a short course of pain medication, for a week, may be necessary, but immediate use of conservative care physiotherapies, acupuncture, and herbal medicine is highly recommended to make sure that the pain is not substantial enough to require pain medication longer than a week.

Discouraging of safer alternatives in NSAID use

Another plant chemical that may be considered in the class of NSAIDS is DMSO, dimethyl sulfoxide, which is mainly derived from seeds, and is a much used polar solvent and ligand. DMSO was found to be able to penetrate the skin and carry other chemicals more deeply into the tissues, and disseminate rapidly in the body, making it an excellent potential carrier for other chemicals in medicine. Research after World War II also uncovered that fact that DMSO was a potent anti-inflammatory. DMSO was first synthesized for commercial uses in 1866 in Russia, and is frequently used as a polar solvent in various chemical reactions involving salts and esters. In chemistry, it is used as an extractant in biochemistry and cell biology. In manufacturing, DMSO is used as a paint stripper that is safe, and thus widely used instead of dangerous chemical paint strippers. In 1963, the University of Oregon Medical School discovered that DMSO could penetrate the skin barrier and other membranes safely without damaging them, and carry other compounds into the biological system. They also found that it was a strong analgesic and antioxidant, and thus could be a useful component to carry anti-inflammatory NSAIDS or herbal chemicals into the body. This research led to a conclusion that DMSO was a type of NSAID, or non-steroidal anti-inflammatory, that comprised a new class of NSAIDS. The response from the pharmaceutical industry was to strongly urge the FDA to do long-term studies to judge efficacy and safety. These long-term studies have apparently never stopped, as the use of DMSO was never approved medicinally by the FDA, without any evidence of harmful effect, other than a bad smell, and the presence of a garlic like taste in the mouth. Such manipulation of the FDA is outrageous, yet completely ignored.

In 1978, the reknowned Cleveland Clinic found that DMSO exerted significant pain relief to a majority of 213 patients with painful genitourinary disorders. They recommended DMSO for all inflammatory conditions not caused by infection or tumor, especially when the pain symptoms did not respond to conventional pain medications. Since then, DMSO in the United States is only approved by the FDA for interstitial cystitis pain and urinary frequency and urgency. DMSO is a restricted chemical in the United States, and purchase of DMSO for medical purposes is very difficult. In fact, purchase of DMSO for other purposes became difficult in the United States. On the other hand, purchase of DMSO for medical use, stripping of paint, and a general solvent in most other countries is not a problem. Animal studies showed that treatment with DMSO within one hour of spinal cord injury could prevent paralysis. One would think that this DMSO would be utilized. It is not. In veterinary medicine, DMSO is used as a liniment in combination with other medicinals, including herbals, and is very safe and effective. In the United States, the pharmaceutical hold on government has been so tight that DMSO is still not used at all in human treatment. The toxicity of DMSO has been confirmed as very low, and the dosage needed in topical application is very small. Instead, a metabolite of DMSO, MSM, or methylsulfonylmethane, is a widely used component of both topical herbal medications, and oral herbal and nutrient formulas. Unfortunately, MSM is not a highly polar solvent, and much less effective as a reactive, ligand, and carrier. The anti-inflammatory effects of MSM are slight compared to DMSO.

One can only speculate as to the number of deaths from NSAID overuse that could have been prevented if DMSO was approved and utilized correctly in the United States.This situation continues today, with little public awareness.

Besides safer herbal and nutrient chemicals for pain relief, simple mechanical means of pain relief such as targeted heat, electrical feedback, and laser phototherapy have been discouraged in the common practice of pain relief despite proof of efficacy. An example of such alternatives to pain medication is seen in the development of the Pain Free Socket by a young woman who started her research and development in high school. Katherine Bomkamp was inspired to find an alternative means to relieve phantom pain for military veterans with amputations after accompanying her father, a disable Air Force veteran to Walter Reed Army Medical Center and hearing the numerous waiting room stories of intense phantom pains from veterans with amputations and prosthetics. While Ms. Bomkamp was not interested in science per se, she became very interested in finding an alternative to the chronic prescription of barbituates and antipsychotic medications prescribed for this neuralgia. She knew from her own experience that the application of heat relieved pain, and proceeded to work with local university engineers to create a prosthetic device that would stimulate peripheral pain receptors with heat to redirect the pain reaction in the brain, utilizing the concept of thermal biofeedback. Today, she has patented her device and awaits FDA approval. Prosthetics manufacturers are interested in this design as a prototype for more sophisticated devices that may dramatically decrease the dependence on medications that have limited effect and harsh side effects with chronic use. The impetus for such design in standard medicine is nonexistent, and it took a concerned high school student to pursue this simple means of thermal biofeedback. Why? Because the funding for medical research promotes lucrative pharmacological solutions only. We are still awaiting this FDA approval years later, despite the obvious safety of such a device, and other thermal feedback devices have been patented as well, such as the 2014 invention of Radhakrishnan Ramdas et al, and the 2015 invention of Peter J. Dunbar et al, yet are still not FDA approved and still not utilized, despite, or perhaps because of, their potential to decrease the overuse of pain medication.

Corticosteroid injections for pain and topical pain relievers: Another health risk with little awareness by the public

Corticosteroid therapy, a treatment to control the inflammatory processes to ease joint pain, decrease asthmatic bronchiole or tracheal swelling, decrease skin inflammation, or to decrease undesirable immune response in various autoimmune disorders, has long been considered an effective but potentially harmful means to decrease symptoms that are threatening to the patient. The high risk of serious side effects and long term damage to the hormonal, or endocrine system, has prompted most authors of medical texts to recommend that other therapies be tried before resorting to this type of therapy. Unfortunately, since the medical field has increasingly moved away from simpler conservative therapies to a greater dependence on new pharmaceutical approaches, and the pharmaceutical industry has not generated effective medications to treat inflammatory disorders, the use of corticosteroids has become routine rather than the treatment of last resort.

The patient should consider and discuss potential side effects with the prescribing doctor when considering this treatment and considering possible alternatives that are less potentially harmful. The National Institute of Health (NIH) gives these side effects as common for patients taking higher doses, and potential for all patients: stomach irritation, muscle weakness, increased blood pressure, diabetes, fluid retention and weight gain, easy bruising, delayed wound healing or tissue repair, glaucoma, decreased calcium absorption and osteoporosis, and decrease in the body's natural production of corticosteroid hormones. In addition corticosteroids, even applied topically, have consistently shown to cause birth defects in laboratory animals. Corticosteroids may also lower your resistance to infections and make infections hard to treat. After prolonged use there is usually a prolonged time of adjustment, lasting up to a year, with side effects of muscle and joint pain, reappearance of disease symptoms, shortness of breath, tiredness or weakness, headaches, nausea, dizziness, fainting, abdominal pain, low fever and loss of appetite.

Since there are a number of corticosteroid hormones produced naturally in the body, the taking of a particular synthetic corticosteroid will inhibit various other natural corticosteroid functions. The body utilizes corticosteroid chemicals to regulate and control many processes in the body. Depending upon the patient's health history, this effect could be dramatic or go unnoticed. In addition, since the hormonal or endocrine system operates on an elaborate feedback mechanism, and many hormones are converted to other hormones as needed in this system, the other steroid hormones in the body will potentially become deficient over time. This is the reason that diabetes is a common side effect, since the pancreas is an endocrine gland and insulin and glucagons are steroid hormones. In addition, a study at the Dept. of Pharmacy and Therapeutics at the University of Pittsburgh (PMID:16901792), found that: "Hyperglycemia occurs in a majority of hospitalized patients receiving high doses of corticosteroids." This effect is seen in corticosteroid injections as well as oral dosing.

The most common type of corticosteroid, the asthma inhaler, has acquired a number of warnings from the FDA in recent years. Many of the inhalers now prescribed combine long-acting beta-adrenergic inhibitors with corticosteroids to increase the effectiveness. Inhibiting beta-adrenergic response quiets the bronchial spasms, while direct corticosteroid application inhibits the inflammatory swelling of the bronchioles. Government warnings state that even though these medications may decrease the frequency of asthma episodes, they may make episodes more severe, and in some patients, these severe episodes have ultimately ended with a fatal asthmatic event. Studies have shown that patients have increased the frequency of use of these inhalers, increasing the risk of severe episodes. This points to the fact that for many patients, frequency of asthma attacks have also increased with use. The physiological reason that the asthma has worsened with use is that the body's natural hormone reactions are being inhibited. A new type of asthma medication, Alvesco, was created to help with the problem of adrenal damage from chronic use of asthma corticosteroid albuterol. This new version is designed to inhibit release into full circulation by requiring a metabolic step to activate the corticosteroid. Alvesco was created due to clinical studies showing widespread injury to adrenal health with chronic use of corticosteroids.

The effects of long term use of corticosteroid therapy has been well documented. For example, studies at the Albert Einstein College of Medicine in New York (PMID:1682792) showed that: "Long-term low dose corticosteroid use may reversibly decrease B-cell counts and specific antibody responses." While this may produce desirable effects with specific symptoms, it may also produce many undesirable effects on the whole immune response in your body, with increased risk of other diseases and infections. The risk of tuberculosis dissemination and fungal overgrowth, such as candidiasis is well documented. The medical faculty of the University Hospital Clinics in Barcelona Spain (PMID:8941496) concluded that: "Osteoporosis is one of the most serious adverse effects experienced by patients receiving long term corticosteroid therapy." Inflammatory bowel conditions and relative lack of weight bearing exercise may increase the risk of corticosteroid induced osteoporosis, and postmenopausal women are particularly at risk. The most rapid bone loss occurs in the first 12-24 months after starting corticosteroid therapies (PMID:10769436). Steroid use has been found to cause fat cell enlargement resulting in blockage of veinous blood return in bone and leading to bone deterioration and small fractures (Univ. of Washington Radiology, www.rad.washington.edu/maintf/cases/unk54/answers.html). Cataracts are also a frequent side effect. The incidence of cataracts in the normal population is 0-4%, but in chronic users of steroid therapies at moderate dose, 30-40% are found to get cataracts, and over 80% will acquire cataracts at high long-term dosage (National Institute of Neurological Diseases and Blindness, NIH grant, Washington Univ. School of Medicine, St. Louis Mo.)

Studies have also linked chronic use of inhaled corticosteroids to such common problems as snoring and sleep apnea. A 2002 study at the University of Wisconsin School of Medicine and Public Health, cited below, found that there was an association of high risk for obstructive sleep apnea for patients using inhaled corticosteroid medications habitually for asthma control. Obstructive sleep apnea also has a high association of risk in cardiovascular medicine for heart attacks and strokes. While simply stopping the use of coricosteroid inhalers is not possible for most asthma patients, the decrease in the chronic use of these corticosteroids is possible by utilizing Complementary Medicine to calm symptoms, promote healing of the bronchiole membranes, and improve immune responses over time.

Does a regimen of calcium supplements with vitamin D prevent this osteoporosis? A large study by the Womens' Health Initiative in 2005 showed little if any effect from this regimen in prevention of osteoporotic fractures in menopausal women, yet a military study showed that large dosage supplementation decreased incidence of stress fractures in young healthy women undergoing strenuous training. This seems to suggest that utilization of the supplements is the key, with hormone deficient women showing problems in utilizing calcium supplements. This is because calcium is the most regulated nutrient in the body. A more holistic approach to dysfunction in the calcium metabolism and regulation is obviously needed, yet stubbornly ignored.

Are patients on corticosteroid therapies being monitored for long term side effects? There are few reports of systems of monitoring for side effects after administering these therapies. There are few reports of studies on the follow up of corticosteroid therapies, especially in the United States. In Australia, a study was conducted at the Universtity of Tasmania School of Pharmacy (PMID:10886467) and concluded from a randomized review of 212 patients consecutively admitted to a large hospital and receiving long-term corticosteroid therapies, such as inhalers, oral meds, or injections, that less than 20 percent of these patient were being tested for bone density decreases and less than half had had blood glucose tests administered in the last year. There is little data to show any follow up in the U.S.

The use of steroids in the United States, despite long years of warnings from research, has continued to increase. Even over the counter products, including beauty products, now routinely use synthetic steroids without having to print warnings. A 2010 article in the New York Times outlined how skin lighteners have brought many patients to the medical clinic with alarming problems. The article outlines how steroids added to the creams upset the immune and hormonal responses in the body, producing thin skin, bruising, stubborn acne, and other side effects. The synthetic steroids are listed as ingredients, but there are so many different chemcicals now that the names on the ingredient lists mean nothing to the consumer. Clobetasol propionate is one of the steroids mentioned in the article, which is a potent synthetic steroid, but the label only states that the product should be used only as directed by a physician, even though it is sold over the counter. Counterfeit health and beauty products are also becoming common, and use of synthetic steroids in these products is now common to increase immediate effects. The consumer in the United States may be taking an array of low dose synthetic corticosteroids unwittingly.

Cortisone shots for the relief of joint pain

One of the most prevalent uses of synthetic corticosteroids is the cortisone injections commonly used to treat joint pain. An October 28, 2010 article in the New York Times Health section reviews the history of these injections, and new light shed on the efficacy versus harm from cortisone injections revealed in a British Lancet article on 45 randomized trials of cortisone injections and long-term outcomes. It appears that, while these injections bring short term partial relief of pain to about 63 percent of patients, the vast majority of the patients studied had worse long-term outcomes after 6 months than those that received no treatment. The patients receiving cortisone shots also had a 63% increased incidence of relapse, and multiple cortisone injections produced a 57% worse outcome than a single injection. The senior author of the study, Bill Vicenzino, the chairman of sports physiotherapy at the University of Queensland in Australia, stated that many orthopedists routinely prescribed cortisone injections as a wait-and-see therapy, to see if the injury healed on its own after 6 months, with temporary relief provided by multiple cortisone injections, but that it appeared that the cortisone injections impeded the healing. This type of therapy often supersedes actual physiotherapy on the injured tissues. The study authors stated also that the injections were warranted because the stated diagnosis was usually tendinitis, implying that there was an underlying inflammatory problem, whereas in reality, there was a degenerative tissue problem in most cases. In other words, the therapy of choice was dictating the diagnosis. This is common practice in medicine today, and too often, this is because the insurer only pays for the cortisone injection, and routinely rejects actual tissue therapies, and even testing to determine the actual diagnosis, such as an MRI. You may click on this link to read the article: http://well.blogs.nytimes.com/2010/10/27/do-cortisone-shots-actually-make-things-worse/?src=me&ref=general

Not only pain medication alone, but the combination of pain medications and other commonly prescribed pharmaceuticals, as well as alcohol, are now creating a significant number of deaths from prescription drug combinations

A February 13, 2011 article in the New York Times reveals that many of our serviceman coming back from Iraq and Afghanistan have died from taking the prescribed combination of drugs to treat their pain and post-traumatic stress disorders. To read this article, google: for some troops new york times. The article, written by James Dao, describes how a combination of psychiatric drugs and narcotic pain medications with acetaminophen are "increasingly linked to a rising tide of other problems, among them drug dependency, suicide, and fatal accidents - sometimes from the interaction of the drugs themselves." To link to this article, click here: http://www.dispatch.com/live/content/national_world/stories/2011/02/13/ Another notable example in the news include the death of the actor Heath Ledger, who was taking a prescribed combination of pain medications and antidepressants and died from drug toxicity. This problem, largely ignored and hidden from public view, and rarely acknowledged in hospital reports, is now being recognized as a growing and serious threat to public health. The United States military has reviewed all potential treatments to address the growing problem of drug dependency and mortality by U.S. servicemen, and by 2013 has fully endorsed acupuncture as an effective treatment, with high ranking members of the U.S. Military Medical Corps, appearing on documentaries by Dr. Sanjay Gupta of CNN, and the Army Surgeon General promoting both clinical and battlefield acupuncture. This article in the official online publication of the U.S. Army from 2010 outlines the evolution of the pragmatic adoption of Traditional Chinese Medicine by our Armed Services, and the dismissal that these treatments present only a placebo effect or quack medicine: http://www.army.mil/article/47448/

Abuse of prescription drugs for recreational use is a very common problem now, and treatment for abuse of prescription drugs now accounts for a fifth of all treatment admissions in some states, according to the National Drug Intelligence Center. The most widely abused street pharmaceuticals in 2000 were Xanax (a benzodiazepine), Oxycontin (narcotic pain medication), Valium (another benzodiazepine), Dilaudid (a narcotic pain medication), Methadone, Codeine, and amphetamine. The supposed war on drugs has apparently not decreased drug use in the United States, but has created a new market for pharmaceuticals that treat pain, substituting synthetic drugs for natural drugs. These synthetic drugs not only have a similar risk of overdose and withdrawal symptoms, but come with a large number of potential side effects and adverse health effects that their natural counterparts did not produce. The withdrawal symptoms for benzodiazepines are similar to those noted with barbituates and alcohol, with pain, tremor, vomiting and sweating, and account for their addictive street nature. Benzodiazepines make the effects of alcohol stronger, as well as some narcotic pain medications, and warnings about these drug interactions go with these drugs. This is the reason why these drugs are popular on the street, though, and potentially, many prescription drug users are taking these same combinations. The National Institute on Alcohol Abuse states that a combination of alcohol and lorazepam (a benzodiazepine anti-anxiety medication) may result in depressed heart and breathing functions.

Alcohol may have a significant effect on the metabolism and concentration of pain medication as well. The National Institutes on Alcohol Abuse and Alcoholism of the National Institutes of Health reports that alcohol-medication interactions may account for at least 25 percent of all emergency room admissions, with an unknown number of less serious interactions unrecorded or unrecognized. Alcohol may alter the bioavailability of pain medications by competing for enzymes in the liver that metabolize the medication, making more of the drug concentrated in the body, or increasing its effective dose, and harmful effects. Chronic alcohol use, on the other hand, may increase the metabolizing enzymes and result in faster metabolizing of pain medications, making them less effective for pain relief, and resulting in the taking of higher dosages to relieve pain. Alcohol may exacerbate the stomach bleeding and irritation, as well as the inhibition of blood clotting, that occurs with aspirin and other pain medications. Aspirin and other pain relievers may also heighten the effects of alcohol, impairing judgment, and resulting in improper dosing.

Increased use of acupuncture, herbal and nutrient medicine, and effective physiotherapies, for relief of pain, especially chronic pain, will reduce the problems associated with the overuse of pain medications. A society that relies less on pharmaceutical pain management may have less of a problem with abuse of these medications in the future, and less of a problem with harmful and dangerous interactions with other drugs and alcohol. In the May 11, 2014 edition of the New York Times, in an article entitled A Soldier's War on Pain, it was revealed that 5 years prior to 2014, about 80 percent of injured soldiers were prescribed narcotic pain medication at Walter Reed Army Medical Center in Washington, but by 2014, that number had been reduced to about 10 percent. Dr. Christopher Spevak, a pain specialist at Walter Reed stated: "As we decrease the amount of opioids, their healing and recovery has gotten much quicker." Another expert at this reknowned Army hospital, Dr. David Hewitt, stated that: "Employing a drug alone is unlikely to lead to a successful outcome." It is becoming obvious to experts in chronic pain that a more holistic and individualized approach is needed. Integration of Complementary Medicine into the treatment protocol provides that best array of treatments to resolve the underlying causes of chronic pain, addressing a host of health problems and promoting an array of factors governing tissue healing and regrowth in a single treatment with acupuncture stimulation, herbal and nutrient medicines, and physiotherapies.