How to Fix Your Chronic Lower Back Pain III of VIII: Just say no to drugs

This is a continuation in the series

How to fix your lower back pain

Or lower back pain 101: Learn to manage it before it manages you

 big-pharma

This is now the third installment in the series. This article will focus on the pharmaceutical management of lower back pain. If you’re interested in the first two articles, click here for the article on yoga, or here for the article on Pilates.

Let’s start out with this disclaimer:

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I am a physical therapist and pharmaceutical management and recommendation is outside of my scope of practice and thus no advice on how to manage your back pain will be given. Likewise, my guest today, Dr. Laura Davids MD, has put together some of today’s best evidence and best practices mixed with her personal experience for managing lower back pain for educational purposes only and this is not to be confused with medical advice. Only your doctor can give you advice to manage your back pain after a complete history and physical.

Cool? Alright let’s do this! I’d like to start with how pain relievers actually work

Great! Now starting with the good old over the counter stuff

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  • Topical/muscle rubs
    • Menthol (icy hot), Capsaicin, Camphor (tiger balm). These all work on a similar principle, which is to increase blood flow to a given area with mild skin irritation. Increased blood flow does equate to increased sensitivity to the painful area, however they also help to break the pain cycle which usually causes blood to be shunted away
  • Analgesics
    • Acetaminophen (Tylenol) is a great OTC medication that was recently taken out of use during acute lower back pain flair ups.
  • NSAIDs
    • Ibuprofen (Advil), Naproxen (Aleve) & more. These medications are very common to manage any pain and come in many different brands and strengths to best be tailored to specific pain.

Now, onto the medications that require a prescription from a prescribing doctor

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  • NSAIDs (by prescription)
    • We’re revisiting this category because many NSAIDs are to be taken by prescription only. These medications are usually great first line treatment given by a prescribing doctor because they are some of the few (and the only ones that will be mentioned in this article) that actually treat the problem as opposed to masking the pain associated with injury. They do this primarily by decreasing inflammation (hence the “anti-inflammatory” name).
    • Like any other medication taken, there are side effects and risks. NSAIDs can have a negative effect on the GI system (stomach/intestines), cardiovascular system, and renal system (kidneys). These negative effects can worsen over time- which is why, for example, medications to protect the lining of your stomach may be given at the same time to prevent ulcers.
  • Muscle relaxants
    • This category of medication is great for muscle stiffness or tightness. Many of these, though not all, do cause some significant drowsiness. An example of a medication that has shown to have minimal drowsiness in the general population is Lorzone. Though these medications can be given for chronic pain, they work much better for more acute pain.
    • As the name suggests, these relax tense muscles so taking them when you have radicular pain (traveling pain down the leg for example) may not be all that beneficial. One point to mention: obviously always tell your doctor all the medications you are on; There is an issue with mixing muscle relaxants and anti-depressants, so make sure your prescribing doctor is aware if they prescribe one while you are taking the other.
  • Opioids
    • This category of medications is usually given to severe pain that is acute in nature and will likely resolve. This tends to be a last resort medication for many reasons, but primarily due to its addictive nature. Before going any further, if you or someone you care about is having an issue with use/abuse in regard to opioids please call (877) 978-3174 for help.
    • These medications affect how the nerves that carry pain to the brain perceive pain in the body. The most common side effect with any of these medications are sedation and generalized drowsiness. These effects get worse with prolonged use.
    • While morphine is a pure opiate, many medications are mixed with non-narcotic analgesics (pain-relievers) to produce a certain effect. For example, Vicodin and Percocet are a mix of opioids and Tylenol, which means taking Tylenol along with these meds could cause serious harm and should be avoided.
  • Neuropathic agents
    • This is the medication most commonly given for neuropathic or nerve pain. Pain that could be described as burning, shooting, or lancinating is best treated with these medications- more so than muscle relaxers or opioids. Treating radiculopathy (i.e. pain shooting down your leg from disc herniation) is off label, meaning it has not been approved by the FDA for that specific use. Despite being off label, it is oftentimes prescribed for radiculopathy.
  • Topical
    • Lidoderm patches are off label for most pain, but are used very often. Unfortunately, this type of treatment is very costly. Lidoderm patches work by numbing the immediate area. Many people have positive results with this transdermal treatment, however, it should not be used by anyone with dysrhythmia or issues with the rhythm of their heart.

PEARLS:

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-Be sure to always read the label of your medications or compounds and know what is in each one and tell your doctor what you’re taking even if it is over the counter, not legal, not prescribed to you.

An example of the danger in not telling your doctor about a medication could be if you’re self-treating with Advil and get prescribed Mobic. The amount of NSAIDs in your body could be dangerous.

-Always be knowledgeable of side effects and know that if you ever need to call your doctor or an ambulance, do not hesitate.

-Many people take aspirin because it protects your heart, but if you take NSAIDs as well, you will end up counteracting the cardioprotective effect.

-Ask your doctor what medications should be taken daily vs. as needed. For example, gabapentin and lyrica are both to be taken every day whereas NSAIDs and muscle relaxants are often prescribed to be taken as needed.

-Most common side effect with these medications is drowsiness and thus operating heavy machinery should be avoided. Because there is no way to know how drowsy someone might get from the medications, it is recommended to take them for the first time at night to assess the strength of sedation.

-Do not take anybody’s medications and do not share yours, ever.

A special thank you to my amazing wife who helped me with this article. She’s an MD based out of Suffolk county board certified Physiatrist. She’s an incredible doctor, an incredible wife, and an incredible incredible mother to our daughter. Thank you for all you do (Also, happy birthday today!!!).

Thank you for reading this. We both appreciate your taking time to better educate yourselves on the wild world of pharmaceuticals in the management of your lower back pain.

Next week I tackle acupuncture and massage therapy for the treatment of lower back pain.

Be well

Dr. Daniel Davids PT

(646) 733-4737

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