Neck and Back Pain Medications – Their Use and Misuse
Medications can be used to modulate many functions in the body. They may actually change the physiology of the damaged tissue or simply block or alter transmission of signals to and from the brain. Medications can be used for pain control, to reduce muscle spasms, reduce inflammation, slow or stop nerve signals and increase an important but depleted neurotransmitter substance. Most of the time, medications cause a temporary reduction in the pain and discomfort. There are occasions, however, when they can cause a more permanent reduction in the pain.
Medications can be divided in terms of temporary relief, medium term, long term and possibly curative potential. Temporary uses are such that someone may come in with severe pain, but the course of their problem will be very short term and time limited. Keeping these patients comfortable while the damaged tissue heals requires sometimes large doses of medications on a declining use basis. Once the painful phase is gone, they can comfortably be taken off the medication and start therapy.
Some patients that have severe pain require immediate surgery and their relief will occur as soon as they wake up from surgery. In this case, strong medications keep them comfortable until surgery can be scheduled.
Medium term patients are ones that can be made comfortable only after an involved rehab program and activity modification. Sometimes, surgery is an answer for them but surgery is not contemplated until they have gone through an extensive recovery program. To keep them comfortable, medications are used to allow them to rehab with less pain.
The long term patients are really “chronic pain” patients. Either their problem will not respond to rehabilitation, they don’t want to undergo surgery or there is no surgery that can help them. These patients are in a special group that requires sometimes lifetime medications. The standard protocols to help pain patients don’t apply to them and their medication programs are very different.
Classifications of Neck and Back Pain Medications
Medications can be classified by their actions. Some stop pain through the opiod pathway, some by stabilizing nerve membranes and some by reducing the inflammation around the pain receptor.
Narcotics are the most commonly thought of substances for back pain. They are essentially natural or synthetic products derived from the opium poppy. These medications can be very effective to block pain if used appropriately. Narcotics attach to naturally occurring opioid receptors in the brain, spinal cord and peripheral tissue to block pain signals. These would be wonder drugs except for two significant drawbacks.
One is that narcotics attach not only to pain receptors but also attach to other brain receptors that involve dopamine. In some patients, this stimulates a euphoric effect- in effect, “a high”. This consequence is the reason why these drugs can be so addicting to some individuals. They also act as a depressant, which is larger doses, can cause the brain’s drive to breathe to become significantly reduced, sometimes fatally.
The other problem with this category of drugs is the issue of becoming less effective with long-term usage. When opioid receptors in the brain and body are blocked or “full”, the brain and body go about creating more receptors. These new receptors again allow the transmission of pain. The new receptors then require more amount of narcotic to cover them. This cycle can continue to go on until the amount of narcotic needed for pain relief becomes excessive. This process is called tachyphylaxis. Eventually, the respiratory drive can be depressed before pain relief can be achieved, leading to death.
Still, with the understanding of these drawbacks, short-term use of narcotics remains the most valuable treatment for acute pain and some types of chronic pain.
Narcotics can be classified in regards to strength, length of effect, and potential side effects. It is important to understand that many narcotic preparations today contain Tylenol and occasionally aspirin. Total Tylenol dosage should not exceed 3000 mg. per day. Patients with liver problems should not have Tylenol and ulcer patients should avoid aspirin. Kidney patients need to reduce the amount of aspirin and Tylenol they use.
The first group is the least potent and most commonly used for mild, chronic pain and occasionally acute pain. They include Tylenol with Codeine and Ultracet. These have very limited addictive potential but give reasonably good pain relief. Many patients that have chronic problems are on these medications and they seem to have the least amount of abuse and hypersensitivity potential.
The second group includes Vicoden (hydrocodone) and its derivatives. This is a group that can be used for chronic pain but does have some additional addictive potential. These products are reserved for patients with increased pain and occasionally, longer term use.
The third group includes Percocet and its derivatives (oxycodone). These drugs are more effective because of their higher potency and therefore more liable to be used by those seeking the “euphoric high”. They have more potential for abuse and sensitivity to them develops more quickly. These are the narcotics most commonly used for post-operative pain control and occasionally are useful for longer term use.
Oxycontin is a newer narcotic and is basically timed released Percocet. Percocet has only a 4-hour life span in the body. Oxycontin delivers 12 hours of medication without that peak and therefore, better pain control with not as much euphoria.
The highest potency narcotics are dilaudid, morphine and fentanyl as well as methadone. These are used for severe post-operative pain, cancer pain, and occasionally, chronic pain syndromes. They are used for patients with severe back pain and are not ideal because of their addiction and sensitivity problems.
NSAIDs (NonSteroidal AntIflammatory Drugs)
These medications are of the class similar to aspirin. Aspirin was initially discovered by Native Americans as it comes from the bark of the wintergreen tree, Ibuprophen (Motrin) was the first large scale manufactured NSAID and the first over the counter NSAID. These all work by blocking the conversion of arachodonic acid into prostaglandins. Prostaglandins cause inflammation and pain nerves to become sensitized. If this conversion is blocked, inflammation and therefore pain will be reduced. Unfortunately, prostaglandins also help to protect the stomach lining from acid and in some individuals, NSAID usage can cause ulcers.
There is one 2nd generation NSAID, Celebrex called a Cox-2 inhibitor, which seem to selectively work on non-stomach related prostaglandins. This medication has less chance of causing stomach ulcers. Celebrex however also seems to have a higher association with cardiac problems. A benefit is that Celebrex works for 24 hours, meaning this is taken once a day. Unfortunately, the price of Celebrex is higher than other prescription NSAIDs. Individuals with cardiac issues should not take Celebrex.
To be most effective, non-steroidals generally need to be taken prior to the activity that will cause the pain. If you are planning a day of hiking, take the medication before you head out in the morning. Also remember that Motrin lasts for 6 hours, so a repeated dose may need to be taken during the activity. Naprosyn (Aleve) does last for 12 hours, so there is less need to repeat doses.
If a patient takes any non-steroidal on a daily basis, every 6 months it is recommended to have a liver profile lab test. There are rare patients that develop liver dysfunction after chronic usage of NSAIDs. If that does happen, most patients improve after stopping the medication.
One major problem with these medications is their capability to reduce the ability of bone to heal after a fracture or even after surgery. Because of this, it is not recommended to use aspirin or NSAID for 3 months following a spinal fusion or fracture.
Tylenol is a very good medication. It has the properties as a pain-killer and anti-fever drug. It doesn’t have the anti-inflammatory effect that NSAIDs do which is both a benefit and a problem. Tylenol’s benefit is that it will not cause stomach problems which is the major side effect of NSAIDs. Tylenol will not however, reduce inflammation, which is the major benefit of NSAIDs. The maximum dosage is 3000 mg per day. This is an important number as many products such as percocet, darvocet and vicodan all contain Tylenol. An individual may take Tylenol in addition to the above medications at the same time and unknowingly overdose. Since Tylenol does not affect bone healing, patients can use this medication after a spinal fusion.
This group of medications acts as central depressants (they enter the brain and spinal cord to reduce the input of nerve stimulation to the muscles). Most of these are quite effective to relieve spasm. The price to pay is mild depression of brain function as these substances also act as a sedative. In fact, one of the indications for these drugs is anxiety. They are good for chronic muscle spasm but have great abuse potential. The prototypical medication in this category is Valium (Diazepam). Addiction to Valium is a very difficult condition to treat. This same category of drug can also used as a sleeping aid, important to remember when operating machinery.
There are exceptions to the standard muscle relaxants. One is Flexoril. It is not in the same category as the benzodiazapines of which Valium is a member and has less “tiredness” associated with it. It is an offshoot of the tricyclics, which were originally designed for depression. It is not addictive but can make some people “out of sorts” like the affects of Benedryl.
Zanaflex (Tizanidine) is a medication to reduce muscle spasticity. It has a different action than typical muscle relaxants or Flexoril. Patients with chronic pain, nerve injury causing spasm and night cramping may benefit. Baclofen (Lioresal) is a medication that was developed for muscle spasm in spinal cord and multiple sclerosis patients but can be effective in patients with cramping and spasm.
Neck and Back Pain Medications for Chronic Pain
Pain, as we now know, occurs from pain receptors (nociceptors) that are triggered when tissue destruction occurs. This allows us feedback to pull away from a hot surface or to react to an injury (fracture). There are times however, when the pain nerves themselves are injured and trigger from minimal or even no stimuli. This is called neuropathic pain. Neuropathic pain does not respond well to narcotics or muscle relaxants. What is interesting is that we have found some help from the treatment of epilepsy (seizures).
A seizure focus in the brain is a group of injured neurons that tend to fire without provocation. These nerves are highly sensitive and trigger with minimal or no stimulation. The brain reacts with an amplification response that takes over and the individual ends up with a seizure. Medications to help this condition stabilize the membranes of these sensitive nerves so they will be less likely to trigger.
We have found that some of these medications work in the same way with peripheral nerves. The use of these can significantly reduce the pain signals by reducing the pain nerve’s ability to propagate the impulse. Of course there can be side effects to this class of medications. One of the most frequent complaints is a feeling of tiredness. In most people, this effect disappears after 1-2 weeks. In those who have continued lethargy, the medication is reduced and then stopped.
The most common ones are Neurontin, Tegritol and Topamax and now Lyrica.
These medications have 3 benzene rings and therefore are called tri-cyclics. They are older designs of some antidepressants. They have been found to be effective with patients who have sleep disorders and for fibromyalgia. In depression or fibromyalgia, the individual has a problem with getting to sleep and their sleep cycle is distressed. This, in turn causes waking hour irritability. Using these medications can break the sleep cycle disruption and help to make the patient more rested.
Injectables for Neck and Back Pain
Obviously, taking an oral medication takes time to get into the system. The medication has to go through the gut and then become absorbed. Also, some of the medication passes right through the digestive tract and doesn’t get absorbed. The medication when taken orally becomes distributed throughout the body and does not get concentrated where it is needed.
Giving the same medication through an IV allows a quick, predictable exposure to the medication but again distributes it throughout the body. Injecting it directly into an involved area concentrates the medication where it can be most useful.
These substances “numb” an area they come in contact with. They temporarily stop the conduction of sensory and in higher concentrations, motor nerves, so there will be no pain (and sometimes motor) transmission until they “wear off”. These medications are useful for minor surgical procedures and to diagnose a pain generator by numbing it temporarily.
These naturally occurring substances are the most powerful anti-inflammatories we possess in our arsenal. These medications significantly reduce or stop the nerve pain that occurs from irritation and reduce swelling. This is the one substance that can actually alter the normal course of a back problem. When this is delivered at a higher concentration, it can reduce the inflammation stage (remember- this stage causes the pain) and “cure” the pain. It is not always successful and has some side effects so it has to be used sparingly.
Local injection of narcotics can be highly successful at reducing pain, especially if injected in the dural sac that surrounds the spinal nerves. If injected into the dura, these medication don’t have the same euphoric effects as if they were injected into a vein. The problem with this group is that they wear off quickly (within 4-24 hours) and can cause respiratory depression. These medications can be constantly delivered by an implantable spinal pain pump.