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Chronic Pain

How Safe Are NSAIDS, Anyway?

People with chronic pain fear opioids but NSAIDS aren't totally safe, either

So there I was at midnight, night after night, my neck pain screeching at a 10+++ on a scale of 10, popping ibuprofen by the handful, dutifully worrying about the well-known dangers of a painkiller-induced stomach bleed, but reassuring myself, “At least these pills are safe – not like opioids, the really dangerous stuff.”

Oops. Not quite right. It turns out that I, like many other people with chronic pain, had gotten my worries somewhat backwards: being overly fearful of opioids, which, of course, do have considerable risks, but not worried enough about NSAIDS — non-steroidal anti-inflammatory drugs — such as ibuprofen, Advil, Motrin, Nuprin, Aleve and others.

My mixed-up worries came straight from newspaper headlines, which play up the dangers of opioids (narcotics), and less frequently note the growing evidence for the risks of NSAIDS as well.

But a major new study in the medical journal The Lancet is helping set things straight. In it, British researchers pooled data from an impressive 639 randomized studies involving more than 300,000 patients, comparing various types of NSAIDS to each other and to placebo.

They found that both so-called “coxibs” (anti-inflammatory drugs such as Celebrex) and high doses of traditional NSAIDS such as ibuprofen raise by about one-third the risk of major “vascular events” such as non-fatal heart attacks, strokes and death. These newly-appreciated risks are in addition to the well-documented risks of gastrointestinal bleeding long linked to NSAIDS.

Put differently, the researchers found that for every 1,000 people with a moderate risk of heart disease taking high doses of the NSAIDs ibuprofen (2400 milligrams daily) or diclofenac (150 milligrams daily), about three would suffer a preventable heart attack, one of which would be fatal.

For unclear reasons, Naproxen (Aleve) seems to carry much less risk, a finding that has shown up in a number of previous studies as well.

This is serious, of course, especially for older people who tend to have more cardiac risks as well as more pain. In fact, because of the risks of NSAIDS, some older people with severe pain have almost no choice but to take opioids — which, of course, carry their own risks, including dependence, addiction, immune suppression, hormonal dysfunction and a greater tendency to fall.

But the news on NSAIDS is not the end of the world, says Dr. Don Goldenberg, chief of rheumatology at Newton-Wellesley Hospital. Though NSAIDS, especially at high doses, can be dangerous, “there is no medication that has no risk,” he says, and three heart attacks among 1,000 people taking the drugs is still a relatively small risk that may well be worth it for people suffering from pain.

For people with rheumatoid arthritis, an inflammatory disease, there are other medications such as methotrexate and biological agents like Enbrel and Remicade that have “revolutionized treatment for RA [rheumatoid arthritis],” Goldenberg says. “We don’t use NSAIDS as a cornerstone for RA anymore.”

For physicians, one clear take-home lesson from the new study is to be more careful about the particular type of NSAID they choose, says Dr. Marie Griffin, a professor of preventive medicine and medicine at Vanderbilt University and the author of a commentary accompanying the new study.

It is also important for patients to tell their doctors how much they think the NSAIDS are actually helping. “If you take NSAIDS and say to me, ‘I can’t tell, or I’m not sure if they’re helping,’ then you talk about it. People have to decide if this is really making a difference.”

It’s also crucial, adds Goldenberg, for both patients and doctors to understand the difference between analgesics, which are pain relievers, and anti-inflammatory agents, like NSAIDS.

With osteoarthritis, for instance, which causes pain but not because of inflammation, it doesn’t make sense to take NSAIDS but may make more sense to take a pain reliever such as acetaminophen (Tylenol), though, of course, acetaminophen has its own potential side effects, including acute liver failure. (Part of the problem is that acetaminophen is often added to cold and cough medications and combined in opioid drugs such as Vicodin, which means that a person can ingest significant doses of acetaminophen without realizing it. Acetaminophen is especially dangerous in combination with alcohol.)

The new data on NSAIDS, particularly the risks of the “coxibs” is particularly disappointing because drugs in this class, called Cox-2 inhibitors, were created more than a decade ago precisely to decrease the risk of bleeding from traditional NSAIDS.

Initially, these drugs were seen as a much safer alternative, but as more and more people began taking coxibs, the risks of coronary disease became more and more apparent. Two such drugs, Vioxx and Bextra, were eventually taken off the market for these reasons.

Although the Lancet study does not discuss non-drug treatments for chronic pain, there are treatments for which evidence for some efficacy exists. Exercise and physical therapy, for instance, can markedly reduce some types of chronic pain, as can acupuncture, massage and other forms of alternative medicine. For people with knee or hip arthritis, joint replacement therapy may also be an important option.

But, sadly, it’s still the case, as Griffin put it in her commentary, “Identification of safe and effective strategies for chronic pain is sorely needed.”

Originally posted on WBUR's CommonHealth blog:


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