Table of Contents
Medication is one part of spine treatment, but it is not a treatment in itself. Medication must be combined with skills such as physical therapy, chiropractic treatment, and exercise to prevent or improve back and neck pain. These skills are the most important means to prevent back and neck problems and treat most types of pain. Medication is best used as temporary assistance in treatment. Medication must be used only for a compelling therapeutic reason, not as a crutch.
In this article, we discuss
• when medication is appropriate for back and neck pain,
• what medications are best for acute pain,
- what medications are best for chronic pain,
- what the side effects are, and
• what medications may worsen symptoms or create additional problems.
Medication is the most frequent treatment for back and neck pain.
Medication is the most frequent treatment by far for back and neck pain. In fact, on the first visit there is a 92 percent chance that a doctor will write a prescription for pain relief. But is that the best remedy? Blindly ordering medication is like getting rid of the smoke rather than putting out the fire. Pain is the result of a symptom. We must ask whether masking the pain will create more problems later if the injury causing the pain persists and does irreparable damage or even whether medications are the cause of chronic pain. Are the potential side effects worth the pain relief?
The medications discussed in this article constitute only a partial list of the medications available. The dosages, usages, and side effects described in this article are based on the best information available when the article was written, but drug usages and warning change constantly. Always consult your doctor or pharmacist to get a complete list of side effects and medication interactions.
For example, opioids such as Vicodin and Demerol can lead to both physical and psychological addiction. Anyone suffering from chronic pain and those who live with them agree that fatigue, depression, irritability, occupational limitations, and relationship struggles appear in the aftermath of excessive drug use.
In this article you will find a concise guide to the medications that treat back and neck problems. Pharmacological treatment should have these three objectives besides pain relief:
1. Treat the cause of the pain (for example, stopping or decreasing the inflammatory process associated with spine injury)
2. Increase pain tolerance by increasing hormones and neurotransmitters and blocking pain generators called nociceptors
3. Suppress pain that causes sleep loss and stress, which impair the immune system and pain modulating hormones, thus retarding recovery
The physician and patient must understand the benefits and the burdens of medication. The physician’s job is to be knowledgeable about the process causing the pain and prescribe the proper medications to improve the problem. The doctor must also help the patient be aware of the risks and benefits of that medication and explain how to use it appropriately. Many patients admit that they have taken over-the-counter medication or a friend’s or spouse’s medication. A major cause of bleeding ulcers and liver and kidney damage is taking over-the-counter pain medication without a doctor’s prescription.
According to the guidelines of the American Pain Society and the American College of Physicians, “The challenge in choosing medication treatment is that each class of medication is associated with a unique balance of risks and benefits.” At their initial office visit, 92 percent of patients with low back pain are prescribed one medication. More than 50 percent of patients receive two or more drugs. The most common are a nonsteroidal anti-inflammatory drug (NSAID) such as aspirin, Aleve, or Motrin and a muscle relaxant or opioid (narcotic). Also, Valium (benzodiazepam), steroids, antidepressants, and antiepileptic medications are frequently prescribed.
Mary’s Cautionary Tale
When Mary complained to her doctor of severe neck pain, he gave her a muscle relaxer and codeine with acetaminophen. When her pain didn’t improve, her doctor prescribed 10 milligrams of Valium and Percocet as well as a laxative to ease the constipation caused by the codeine. When she couldn’t sleep, Mary took an over-the-counter sleep aid. Six weeks later, Mary sought additional help, not for her pain, which was under control, but because she was having a hard time thinking, was feeling nauseated, and had lost her appetite. Her skin had a yellow cast from jaundice, a sign of serious liver damage. Mary had been overdosing on acetaminophen, which was in two of her prescription drugs as well as the over-the-counter sleep aid that she was taking. Dangerous scenarios such as this occur frequently when medication is seen as an easy fix.
Successful treatment depends on a proper diagnosis. Because back pain is gen- erated from many body structures—bones, ligaments, nerves, and discs—each having its own voice or pain, we must determine what structure is at fault. Other substances—neurotransmitters, dopamine, and serotonin—and other parts of the nervous system such as the thalamus act as volume controls to those voices. Therefore, a doctor should not prescribe medications and you should not use over-the-counter drugs without a clear idea of the cause for your distress. Remember that medications can help you or harm you.
For most back and neck problems, medication alone is not the best treatment. In most cases, the best approach is to learn to avoid the causes of pain, such as poor posture or inefficient body mechanics, build up the core musculature, and engage in physical therapy and chiropractic treatment. Remember that pain is a warning. Medication for back and neck problems should never be used to hide pain. Instead, medication should treat the cause, provide relief, and allow you to participate in therapy.
First, we review the medications that act on the perception of the pain itself. Second, we consider those that relieve the muscle spasms that occur as the body tries to protect itself. Third, we discuss medications that influence neurotransmitters such as serotonin, dopamine, gabamine, and norepinephrine, which can diminish pain, elevate mood, and relieve depression, which itself can cause mental pain. Fourth, we consider the side effects of medications. Finally, we consider medications that work on the neurotransmission of pain and modulate or stabilize the nerve membranes and nociceptors. This effect is important in relieving the pain from nerve injury or because of subsequent scarring after nerve root injury (pinching a nerve).
NSAIDS such as Aleve, Naproxen, Motrin, and Celebrex work in the cyclooxygenase reduction-inhibiting prostaglandins that cause inflammation and sensitize peripheral nociceptors (pain-producing cells or sites). The primary reaction of NSAIDs is in decreasing nociceptor or pain-generating cell sensitivity. Studies show that if NSAIDs are used early, less alternative pain medication is needed. Use of more than one NSAID is not advised because of their potential to cause gastric upset such as heartburn. NSAIDS such as ibuprofen inhibit the action of aspirin to prevent heart attacks and stroke when taken within 14 hours of each other. If you take aspirin for heart-related reasons, remember that NSAIDs inactivate the effect of aspirin and increase the risk of heart attack and stroke.
How each medication should be taken depends on the medication’s half-life. Generally, by doubling the half-life you can determine how long the drug remains in the body. Always take medication as prescribed by your doctor but be aware of its half-life.
Aspirin is metabolized in the liver, and its half-life is approximately three hours. It is excreted by the kidneys. Its main side effects are stomach upset and bleeding. Other effects are that it prevents heart attack and stroke.
Medications That Act on the Perception of Pain
|Name||Generic||Dose||Half-Life||Pain Relief Rating *||Best Use||Side Effects||Other Properties|
|Bayer Aspirin Anacin||Aspirin (NSAID) Salicytates||325 mg to 650 mg||3 hours||1 to 2||Acute mild to moderate pain||Stomach upset, bleeding, ulcers||Prevents heart attack and stroke|
|Tylenol||Acetaminophen||500 mg||2 to 4 hours||2||Mild muscular skeletal pain, mild chronic pain, acute back pain||Chronic use can lead to kidney or liver damage. Chronic use is the number- one cause of kidney failure||Does not ease inflammation, help with sleep, or treat the cause of pain|
|Advil Motrin Unpin||Ibuprofen (NSAID)||200 mg||2 hours||2.5||Joint and muscle pain, acute back pain; less effect after 7 days||Stomach ulcers||Increases risk of heart attack and stroke|
|Aleve Naproxen||Naproxen (NSAID)||220 mg||12 to 24 hours||3||Acute joint and muscle pain, acute back pain; less effect after 7 days||Hypertension, stomach ulcers||Increases risk of heart attack and stroke|
|Celebrex||Celecoxib (NSAID)||100 mg to 200 mg||11 hours||3.5||Acute and chronic back pain||Stomach upset is less frequent||Increases risk of heart attack and stroke|
|Ultra||Tramadol||50 mg||5 ½ to 7 hours||3.7||Acute and chronic moderate to severe back pain||Constipation, headache, drowsiness||Seizures, respiratory problems, & depression|
|Vicodin Lorcet||Hydrocodone (H) and acetaminophen (A)||5 mg (H) and 500 mg (A)||4 hours (H) and 1 1/2 to 3 hours (A)||4||Moderate to severe back pain||Constipation, drowsiness, addiction, kidney damage||Addiction and depression|
|Codeine||Codeine||15, 30 or 60 mg||2 ½ to 4 hours||4||Moderate to severe pain**||Constipation, liver damage||Drowsiness, addiction, depression|
|Fentanyl||Eentanyl||50 mg to 100 mg||3 to 7 hours intramuscular, 7 hours transdermal||4 to 8||Severe pain**||Constipation, liver damage, nausea, vomiting||Drowsiness, addiction, depression, slow heart rate|
|Vicodin ES Lorcet Plus||Hydrocodone (H) and acetaminophen (A)||7. 5 mg ( H ) and 650 mg (A)||4 hours (H) and 1 1/2 to 3 hours (A)||4.5||Moderate to severe back pain**||Constipation, drowsiness, addiction, kidney damage||Addiction and depression|
|Demerol||Meperidine||50 mg to 100 mg||3 to 5 hours||4 to 6||Severe acute back pain**||Drowsiness, confusion||Rapid addiction, euphoria|
|Lortab||Hydrocodone (H) and acetaminophen (A)||10 mg (H) and 500 mg (A)||4 hours (H) and 1 1/2 to 3 hours (A)||5||Moderate to severe back pain**||Constipation, drowsiness, addiction, kidney damage||Addiction and depression|
|Norco with paracetamol||Hydrocodone (H) and acetaminophen (A)||10 mg (H) and 325 mg (A)||4 hours (H) and 1 1/2 to 3 hours (A)||5||Moderate to severe back pain**||Constipation, drowsiness, addiction, kidney damage||Addiction and depression|
|Percocet||Oxycodone HCL (O) and acetaminophen (A)||10 mg (O) and 325 mg (A)||3 to 4 1/2 hours (O) and 1 1/2 to 3 hours (A)||5 to 7||Moderate to severe back pain**||Constipation, drowsiness, addiction, kidney damage||Addiction and depression|
|Percodan||Oxycodone HCL (O) and aspirin (AS)||4.5 mg (O) and 325 mg (AS)||3 to 4 1/2 hours||5 to 7||Moderate to severe back pain**||Constipation, drowsiness, addiction, kidney damage||Addiction and depression|
|Dilaudid||Hydromorphone||2 mg||2 to 3 hours||8||Moderate to severe back pain**||Constipation, drowsiness, addiction, kidney damage||Addiction, depression, euphoria; may react adversely with other drugs|
|Oxycontin||Oxycodone HCL||10, 15, 20, 30, 40, 60, 80, or 160 mg||3 to 4 1/2 hours||8.5||Moderate to severe back pain**||Constipation, drowsiness, addiction, kidney damage||Addiction, depression, euphoria|
|MS Contin||Morphine sulfate||10 to 30 mg||2 to 3 hours||10||Moderate to severe back pain**||Constipation, drowsiness, addiction, kidney damage||Addiction, depression, euphoria|
*Pain relief is factored on a scale from 1 to 10, with 1 being the least and 10 being the most. Ratings are estimates based on our review of the medical literature and personal experience.
**Use only during acute phase for no more than six weeks unless advised by your doctor. Chronic use may lead to chronic pain syndrome.
Acetaminophen has an antifever and analgesic action. It works on an area in the brain near the heat regulatory center. Acetaminophen is metabolized in the liver and has a half-life of three to four hours. It is excreted by the kidney. Its major side effects are liver and kidney damage. Because it is often combined with other analgesics, many patients are unaware that when they take acetaminophen in combination with other analgesics, such as Vicodin and Percocet, they are taking double doses of acetaminophen. Over several months, they may damage their kidneys and liver. Always check whether the medication that you are given has acetaminophen and another analgesic. Also, because most drugs are metabolized in the liver and excreted by the kidneys, liver and kidney function should be checked regularly by your doctor.
Check your prescribed medication and note if it has acetaminophen plus another analgesic. Be careful not to take double doses of acetaminophen. If you have questions, ask your doctor or pharmacist.
Morphine and other opioids bind to various opioid receptors, producing pain relief and sedation that cause loss of attention, concentration, and memory. Opioids also have been found to interfere with the normal pain threshold that is modulated by neurotransmitters, such as serotonin. Over a two-week period, an opioid can decrease your natural pain threshold, causing an increase in pain sensitivity after the opioid is discontinued. Through several mechanisms, opioids cause tolerance and a need for increasingly larger doses. Opioids also interfere with the frontal lobe, the home of executive functioning, causing the person on the medication to become ineffectual and unmotivated. Opioid use frequently leads to depression and problems at home and work. For these reasons, opioids should be used only for short periods to treat serious pain and under the strict guidance of a doctor. Opioids are metabolized in the liver and are excreted most often in the urine, bile, and feces.
Morphine and other opioids are addictive when taken chronically. The five predictors of addiction are
- anticipatory dosing (taking medication to avoid pain even when pain is not felt),
- decreased interest such as loss of libido or decreased socialization and physical activity,
- slurred or monotone speech,
- poor recall, and
- poor hygiene and dress.
If your physician prescribes opioids for the long term—more than two months— please sit down with your doctor and discuss alternative methods of treatment or ask for a second opinion. Long-term treatment with opioids should be done only under scrutiny by a physician because addiction to opioids is a major complication and a cause of chronic back pain.
Muscle relaxants are used to treat acute spine pain, improve range of motion, and increase blood supply to the muscles. Muscle relaxants also interrupt the pain–spasm–pain cycle. They are helpful in increasing range of motion and mobil- ity. Muscle relaxants act either on nerve cells in the spinal cord or on the muscle spindle or cells. Some, such as Zanaflex, also inhibit prostaglandins and have an anti-inflammatory effect. They are metabolized mainly in the liver and kidneys. Often, muscle relaxants are associated with drowsiness. Those of the benzodiazepan family, such as Valium, have serious addictive qualities.
|Name||Generic||Dose||Best use||Side effects||Other Properties|
|Soma||Carisoprodol||10 mg daily||Acute spine pain or recurrence||Drowsiness (20 percent)||Increased relief when combined with NSAIDS|
|Baclofen||Baclofen||10 to 80 mg daily||Chronic spasticity||Severe drowsiness (49 percent)||Best for spinal cord injury|
|Valium||Diazepam||10 mg||Not advised||Addictive, drowsiness||Can benefit patients who have severe panic and anxiety associated with low back pain|
|Zanaflex||Tizanidine||4 mg daily, increase to 3 times daily||Acute pain syndrome||Drowsiness||Inhibits both leukotriene and prostiglandins, which produce pain; few side effects if used less than 1 week|
|Decadron Prednisone Medrol||Corticosteroids||Varies according to type||Acute with neurological and nerve root pain||Diabetes, sleeplessness, anxiety||Be cautious of long-term use; best for joint and muscle injury; short term use is 1-2 weeks|
Note this is only a partial list of medications, dosages, side effects, and other information. Always ask your doctor and pharmacist for a complete list of side effects and medication interactions.
The primary mechanism of antidepressants is not their antidepressant effect but the way that they filter the effect of pain perception. The brain has its own mechanism of filtering messages sent to the cortex, the awareness part of the brain. Just as you adjust a nozzle on a garden hose to change the flow of water, you can tighten or loosen the flow of pain to the brain. Fewer pain messages get to the cortex. Antidepressants are metabolized in the liver and excreted in the urine and feces. They increase norepinephrine and serotonin, thereby increasing pain threshold. At first, many patients experience side effects such as dry mouth and mild sedation. Improvement in mood follows. Other side effects are weight gain and interference with sexual performance.
|Name||Generic||Dose||Best use||Side effects|
|Elavil||Amitriptyline||25 mg to 150 mg||Increase sleep and decrease depression||Dry mouth, drowsiness, urinary retention, heart arrhythmia|
|Sinequan||Doxepin HCL||10 mg to 100 mg||Increase sleep||Dry mouth, drowsiness, urinary retention|
|Effexor||Venlafaxine||37.5 mg to 300 mg||Chronic low back pain||Dry mouth, drowsiness, urinary retention, sleeplessness; no cardiac side effects|
|Cymbalta||Duloxetine||20, 30, or 60 mg||Chronic low back pain||Seizure (rare), glaucoma, nausea, dry mouth, constipation, insomnia, sexual problems|
|Savella||Milnacipran||12.5 mg to 100 mg||Chronic low back pain||Seizure (rare), nausea, constipation, insomnia, sweating, weight loss, decrease in libido|
Note: This is only a partial list of medications, dosages, side effects, and other information. Always ask your doctor and pharmacist for a complete list of side effects and medication interactions.
NERVE-MODULATING PAIN RELIEVERS
Nerve-modulating pain relievers work by stabilizing the injured nerve membranes and decreasing the pain perception from nociceptors in various tissues. Side effects include diarrhea, drowsiness, weight loss, and, occasionally, tingling sensations and swelling of the ankles.
|Brand name||Generic||Dose||Best use||Side effects|
|Neurontin||Gabapentin||100 mg to 5,000 mg (divided doses)||Chronic back pain||Diarrhea, drowsiness|
|Lyrica||Pregabalin||25 mg to 300 mg (divided doses)||Chronic back pain||Tingling, burning, shocklike sensations; can cause dizziness, weight gain, swelling of limbs (increased with use of narcotics and alcohol)|
|Topomax||Topiromax||25 mg to 200 mg (divided doses)||Chronic back pain||Drowsiness, severe weight loss, tingling, depression|
Note: This is only a partial list of medications, dosages, side effects, and other information. Always ask your doctor and pharmacist for a complete list of side effects and medication interactions.
Drugs such as prednisone, Medrol, and Decadron are considered the ultimate anti-inflammatories. They decrease swelling and cause a dramatic decrease in pain when the nerve is being compressed, such as with a herniated disc. Corticosteriods can decrease the pressure caused by swelling on nerves and other tissues, relieving the damaging effect on the delicate nerves in the back. In addition, corticosteriods are great inhibitors of cytokinins and prostaglandins, which cause damage to surrounding tissues. Because long-term use can lead to serious side effects to bones, joints, and blood vessels, including hypertension and diabetes, corticosteriods should be used for short-term (one- or two-week) treatment of back and neck pain. The first indication for their use is a certain diagnosis of spinal cord or nerve injury.
USE PILLS WITH SKILL
For most spinal disorders, medication alone is not the best treatment. In most cases, learning specific skills is the best treatment. Learn to avoid precipitating causes such as poor posture or inadequate body mechanics. Strengthen your core through a good exercise program. Perhaps try physical therapy or chiropractic treatment.
Pain is a warning. The medication that you take for your back and neck problems should never hide the problem but should treat the case and give you relief.