The very treatments often used to soothe pain in the lower back, which the Centers for Disease Control and Prevention says is the most common type of pain, could make it last longer, according to a new study.
Persistent use of analgesic steroids and nonsteroidal anti-inflammatory drugs, such as ibuprofen, can actually turn a torn back into a chronic condition, the study found.
Some medical experts have urged caution in interpreting the results too broadly. The study did not use the gold standard for medical research, which would be a clinical trial in which people with back pain are randomly assigned to take a nonsteroidal anti-inflammatory drug or a placebo and followed for see who has developed chronic pain. Instead, it was patient observation, animal study, and patient analysis in a large database.
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“It’s intriguing but needs further study,” said Dr. Steven J. Atlas, director of practice-based research in primary care and quality improvement at Massachusetts General Hospital.
Dr. Bruce M. Vrooman, a pain specialist at Dartmouth Hitchcock Medical Center in New Hampshire, agreed, but also called the study “impressive in scope” and said that if the results hold up in a clinical trial, it could “force reconsideration”. how we deal with acute pain.
Dr. Thomas Buchheit, director of the regenerative pain therapies program at Duke, had a different view.
“People misuse the term ‘paradigm shift,’ but it’s absolutely a paradigm shift,” Buchheit said. “There’s this unspoken rule: if it hurts, take an anti-inflammatory, and if it still hurts, put a steroid on it.” But, he said, the study shows that “we need to think about healing, not suppressing inflammation.”
Guidelines from professional medical societies already say people with back pain should start with non-drug treatments like exercise, physical therapy, heat, or massage. These measures are as effective as analgesics, without the same side effects.
If the pain persists, depending on the guidelines, people can try nonsteroidal anti-inflammatory drugs like ibuprofen. (Acetaminophen is not an anti-inflammatory because it does not block inflammation.)
But the study, published Wednesday in the journal Science Translational Medicine, included a warning that such drug treatment advice could contribute to chronic pain that reduces a person’s quality of life.
The study began when researchers at McGill University began looking for molecular markers in the blood that would predict which patients would suffer from a rapid decrease in pain and which would suffer from persistent pain.
The group took blood samples from 98 people when they said they first developed back pain and then three months after their pain started.
“What we saw was not exactly what we expected,” said Dr. Luda Diatchenko, the study’s principal investigator and a McGill professor who specializes in the genetics of human pain.
Those who said their pain was gone had rapid and intense inflammation when the pain was acute. Inflammation markers then declined over the following three months. Those whose pain persisted did not have such an inflammatory reaction.
“Absolutely nothing was happening” in people with chronic pain, Diatchenko said.
“It was a huge difference,” she added.
Researchers continued to investigate. They studied people with another type of pain, TMJ or temporomandibular joint disorders, which lead to jaw pain. Once again, those who recovered had rapid and intense inflammatory responses.
The researchers also replicated the results in mice, compressing the animals’ sciatic nerves to produce back and leg pain or injecting an irritant into the sciatic nerves. When they blocked the animals’ immune response with dexamethasone, a steroid commonly used to treat back pain, the pain became chronic.
Next, the group discussed whether chronic pain resulted from suppressing pain or suppressing inflammation. So they gave some mice a prescription anti-inflammatory, diclofenac. Other mice were given one of three other analgesic or analgesic drugs – gabapentin, morphine and lidocaine.
Only with diclofenac did the pain persist, becoming chronic.
These results led them to wonder: Were patients who took nonsteroidal anti-inflammatory drugs like ibuprofen or steroids like dexamethasone for back pain also more likely to develop chronic pain?
The researchers turned to data from the UK Biobank, a repository containing information on the medical conditions and drug use of half a million patients. They studied 2,163 people with acute back pain, 461 of whom went on to experience chronic pain. The researchers found that those taking a nonsteroidal anti-inflammatory drug were almost twice as likely to develop chronic back pain as those taking no or no medication.
Diatchenko said she did not believe her findings addressed the issue of opioid addiction. In fact, she says, “to avoid opioids, clinicians have started prescribing more nonsteroidal anti-inflammatory drugs.”
“We need to think more about how to treat our patients,” she said.
The tendency to use nonsteroidal anti-inflammatory drugs persists despite their poor performance. An analysis of randomized clinical trials found that these drugs had almost no benefit over placebos in reducing low back pain.
Atlas says short-term use of nonsteroidal anti-inflammatory drugs probably isn’t harmful, but the new study, he adds, without proving that long-term use is harmful, “gives at least a biological mechanism that says short-term use is not the same as long-term.
Dr. James N. Weinstein, senior vice president for health at Microsoft, wants people to rethink their instincts for taking ibuprofen pills and — as counterintuitive as that might sound — exercise instead. .
Weinstein, who for 28 years was editor of the medical journal Spine and was not involved in the new study, said he went out for runs when his back hurt. It actually makes it better.
“I love it,” he said of the study, “and I know it’s true.”
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