How Do Pain Relievers Work? TED-Education video

From TED Education series, Jun 26, 2012: Some people take aspirin or ibuprofen to treat everyday aches and pains, but how exactly do the different classes of pain relievers work? Learn about the basic physiology of how humans experience pain, and the mechanics of the medicines we've invented to block or circumvent that discomfort.



Lesson by George Zaidan, animated by Augenblick Studios.

Acute low back pain: What to do? What works and what doesn't?

Here is an excerpt from a recent review article in the official AFP journal American Family Physician:

Acute low back pain is one of the most common reasons for adults to see a physician. Most patients recover quickly with minimal treatment.

"Red flags"

Serious "red flags" include:

- significant trauma related to age (i.e., injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis)
- major or progressive motor or sensory deficit
- new-onset bowel or bladder incontinence or urinary retention
- loss of anal sphincter tone
- saddle anesthesia
- history of cancer metastatic to bone
- suspected spinal infection

Diagnosis

Without signs of serious pathology, imaging and laboratory testing often are not required.

Treatment

Patient education, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and muscle relaxants are beneficial.

Bed rest should be avoided, if possible.

Exercises directed by a physical therapist, such as the McKenzie method and spine stabilization exercises, may decrease recurrent pain.

Spinal manipulation and chiropractic techniques are no more effective than established medical treatments.

No substantial benefit has been shown with:

- oral steroids
- acupuncture
- massage
- traction
- lumbar supports
- regular exercise programs

References:

Diagnosis and treatment of acute low back pain. Casazza BA. Am Fam Physician. 2012 Feb 15;85(4):343-50.

Image source: Different regions (curvatures) of the vertebral column, Wikipedia, public domain.

One doctor prescribed more than a million hydrocodone tablets

A California diet center doctor known by patients as “Candy Man” was sentenced to four years in federal prison for dispensing what authorities said were massive amounts of powerful painkillers in exchange for cash.

Records revealed that he ordered more than a million hydrocodone tablets in 2008, more than any other doctor in the nation.

Prosecutors estimated that he made nearly $700,000 that year from selling controlled substances. However, authorities said they couldn’t account for 75% of the pills purchased over a 13-month period because he didn’t keep records of the transactions.

In the meantime, the NYTimes reports that Florida is shutting ‘Pill Mill’ clinics. Florida has long been the nation’s center of the illegal sale of prescription drugs: some doctors there bought 89% of all the Oxycodone sold in the country last year. This has changed dramatically with the introduction of new legislation.

References:
Doc gets 4 years for dispensing drugs for cash. MSNBC.
Florida Shutting ‘Pill Mill’ Clinics. NYTimes.
Image source: public domain.

No NSAID may be safe in cardiovascular terms - naproxen seems least harmful

This BMJ meta-analysis included large scale randomised controlled trials comparing any non-steroidal anti-inflammatory drug (NSAID) with other non-steroidal anti-inflammatory drugs or placebo. Data synthesis included 31 trials in 116, 429 patients. Patients were allocated to naproxen, ibuprofen, diclofenac, celecoxib, etoricoxib, rofecoxib, lumiracoxib, or placebo.

Study outcomes

The primary outcome was myocardial infarction. Secondary outcomes included stroke, death from cardiovascular disease, and death from any cause.

Cardiovascular risks

Compared with placebo, rofecoxib (Vioxx) was associated with the highest risk of myocardial infarction (rate ratio 2.12), followed by lumiracoxib (2.00).

Ibuprofen was associated with the highest risk of stroke (3.36), followed by diclofenac (2.86).

Etoricoxib (4.07) and diclofenac (3.98) were associated with the highest risk of cardiovascular death.

Little evidence exists to suggest that any of the investigated drugs are safe in cardiovascular terms. Naproxen (Aleve, Naprosyn) seemed least harmful.

According to the corresponding BMJ editorial, Celebrex (celecoxib) is not much safer either: "All cyclo-oxygenase-2 inhibitors studied in large placebo controlled trials have been found to confer an increased risk of serious cardiovascular disease. This suggests that patients with a high risk of cardiovascular disease should avoid cyclo-oxygenase-2 inhibitors (COX-2). "

References

Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ 2011; 342:c7086 doi: 10.1136/bmj.c7086 (Published 11 January 2011)

Editorial: Cardiovascular safety of NSAIDs. Wayne A Ray. BMJ 342:doi:10.1136/bmj.c6618 (Published 11 January 2011)

Image source: Wikipedia, public domain.

Old drug, new warnings: Acetaminophen (paracetamol, Tylenol)

Acetaminophen is the leading cause of acute liver failure in the United States. Nearly half of acetaminophen-associated cases are due to unintentional overdose.

Especially vulnerable patients are:

- taking enzyme-inducing drugs
- chronic users of alcohol
- malnourished

Although no consensus has been reached on what is a safe dose in patients with liver disease, 4 g/day is too much: a total daily dose of no more than 2 g is recommended to decrease the risk of toxicity in these patients.

The US Food and Drug Administration (FDA) is considering banning acetaminophen-narcotic combination products.

References:
Acetaminophen: Old drug, new warnings. Cleveland Clinic Journal of Medicine January 2010 vol. 77 1 19-27.
Image source: Amazon, used for illustrative purposes only - NOT a suggestion to purchase any medications.