Anti-inflammatories & Pain Killers
In this section we will be discussing the more commonly prescribed medications for whiplash and spinal pain overall. We’ll also discuss some sidebar issues like related statistics, chances of harm, error rates not to mention others. I am not a medical physician or a pharmacist. Always consult with your medical physician before changing and /or stopping your medication regimen. That said, everything I am extolling here is information easily accessed by members of the general public. What I have done is bring together what I feel is some of the more pertinent information regarding whiplash and spinal pain in general.
Every new drug that comes to market is typically peppered with its weight of public relations extolling its virtues and how much better it is than its predecessor. With that here is a sample of the list of drugs that have been pulled from the market, after much hype and accolades about their benefits over their predecessors, and when:
- Zelnorm – March 2007.
- Vioxx – September 2004.
- Propulsid – March 2000.
- Bextra – April 2005.
- Redux – September 1997.
- Duract – June 1998.
- Rezulin – March 2000.
Public Citizen Health Research Group (www.citizen.org) is a United States based organization that promotes research-based changes to health care policy. They also provide oversight concerning drugs, medical devices, medical doctors, hospitals and occupational health. They accept no funding from government agencies, corporations or professional associations thereby maintaining a level of independence and autonomy far exceeding many other organizations in the health care arena.
Their 2005 publication Worst Pills, Best Pills: A Consumer’s Guide to Avoiding Drug-Induced Death or Illness (www.worstpills.org) was researched by a panel of experts from the fields of medicine, pharmacy and public health.
To assist the public in outlining different drug’s safety and efficacy they group them into 2 categories of “limited use” and “do not use.” By being under the limited use umbrella it means there are other drugs in that category that are more effective and/or less severe side effects. A do not use drug means drugs in this category should never be used due to the high potential for serious side effects.
In 1998 the Journal of the American Medical Association published an article that for the first time put the number of adverse drug reactions (ADR) occurring in the United States into perspective. The article reported that with 106,000ADR’s having occurred in 1997 that made ADR’s the 4th to 6th (depended on how the actual numbers were reported) leading cause of death in the US. Couple that statistic with the established number of serious, non-fatal, complications pegged at 2.2 million and you can see they saw a real issue that had to be dealt with. All tolled the fatal ADR’s, when combined with the number of people admitted to hospital for ADR’s, were pegged at about 4.6% of all recorded deaths in the United States.
Soon thereafter the U.S. FDA created the Adverse Event Reporting System (AERS) which goes under the more popular name of Medwatch. Thanks to this new reporting system it was noted that between 1998-2005 serious ADR’s increased 2.6 times and fatal ADR’s increased 2.7 times. Put another way, serious ADR’s increased at a 4X faster rate than the number of outpatient prescriptions written for the same period.
ADR’s do not include dispensing errors and intentional overdosing of prescription drugs, these come under the heading of Adverse Drug Events (ADE).
In 1994 63,000 fatal ADR’s were reported is U.S. hospitals. A Meta-Analysis of prospective studies, published in the Journal of the American Medical Association. The Mets-Analysis spanned 4 decades and many great changes occurred over that time, but no corresponding changes occurred in the rates of ADR’s. The actual direct hospital costs were pegged at $1.56-4 billion a year in the U.S.
Don’t think this is just a North American problem. A 2004 study published in the British Medical Journal laid out the U.K’s stats for all to see. ADR’s were directly responsible for 6.5% of their total hospital admissions for a total of $847 million (U.S.). Of note was that the largest numbers of admissions were due to NSAID’s and diuretics.
In 2005, NSAID’s accounted for 33,000 deaths, mostly due to gastrointestinal bleeding. Note that number was after COX-2’s were pulled from the market.
For causes of fatal ADR’s the opiate drugs top the list. The one responsible for the most deaths is Oxycodone which is the active ingredient in Oxycontin, Percocet, Percodan, etc. Number 2 is Fentanyl, which is multiple times more powerful than Morphine. It’s typically prescribed to the general public in the form of patches called transdermal Duragesic.
Coming in at number 5, for fatal ADR’s, is Acetaminophen. It’s the active ingredient in Tylenol, Motrin, Excedrine, Pamperin, etc. and it’s available over the counter. Short of a prescription it is close to the top of the list for medical doctor recommendations for typical neck and back pain. We’ll discuss this drug further under the heading Pain Killers.
The types of injuries we are talking about here are ‘acute’ (macrotrauma) and ‘chronic’ (overuse, microtrauma and overuse). Both types of injuries are subject to 3 stages of tissue responses in the human body. They occur in response to the bodies attempt to heal itself: 1) Acute vascular inflammation. 2) Repair and regeneration. 3) Maturation.
The pathophysiology (how it happens) of pain production and inflammation can get quite involved. Suffice to say this web site is principally geared to the general public so I don’t see a need to go into great depth about the biochemical pathways. Basic biochemistry texts are readily available at your nearest library, not to mention the internet.
Understand that for cases of severely acute whiplash and/or spinal pain, then yes medication absolutely has a role to play. In my own practice it is not uncommon for me to send patients, who present in so much pain I can’t even perform the most basic movements with them, to their family medical doctor for medication to get through the first few days of the acute phase. Unfortunately a treatment approach that is subject to much debate is when the acute phase ends and the patient continues on the road of strictly medication.
Aside from aspirin (highly corrosive on the gut) an expert panel (appointed by Health Canada) concluded all NSAID’s increase the danger of cardiovascular ‘problems’. It should be pointed out, for both the United States and Canada, the pharmaceutical companies remain hands down the greatest source of funding for medical research. This section of the web site is not to bash ‘big pharma’. Quite the contrary, they are to be respected and thanked for having created some of mankind’s greatest discoveries. At the same time they also gave us Thalidomide and Diethylstilbestrol. The moral of the story is consumer beware. Blind faith in the almighty prescription pad carries inherent risks. Hopefully this section, along with the others, will assist in generating some questions for you to ask and provide food for thought.
First off don’t be too hard on the medical doctors. In their defense they do the best they can, but as I have eluded to elsewhere they can’t be all things to all patients, contrary to what the ‘spin doctors’ would have us believe. There is an intense pressure on doctors to push NSAID’s. In fairness to them it should be pointed out that they are quite literally inundated with what the National Post’s columnist Colby Cosh has referred to as “drug hype.” He has also investigated this area and stated the medical physicians accept “small scale bribery by schmoozing pharmaceutical reps”.
Perhaps a quote from a Toronto medical doctor will help. Dr. D.Rapoport said it best when he stated “Drug reps shower me with so many samples of COX-2 inhibitors for arthritis I seldom have to write a prescription. One rep gave me an entire case, which lasted for months. There is no doubt that this abundance makes me more likely to reach for them as an alternative.” He went on to state, which are words for all medical doctors to live by, “Sometimes when I reach for my prescription pad, I treat it like a loaded weapon, to be used with extreme caution if at all.”
Anti-Inflammatories
First off, let’s delve into the world of anti-inflammatory medication. They are termed Non Steroidal Anti-Inflammatory Drugs (NSAID’s).
In 1971, Sir John Vane proposed NSAID’s primary action to reduce inflammation. Suffice to say NSAID’s inhibit pro-inflammatory mediators called prostaglandins as well as inhibit the cyclooxygenase (COX) enzyme responsible for converting what is known as arachadonic acid to terminal prostaglandins (they promote inflammation) and excite/sensitize various neurons -> pain). The end result is after an injury the COX-2 enzyme levels increase anywhere from 10-80Xduring inflammation. Remember not all inflammation is bad. As mentioned earlier it is a required stage in the healing process.
Let’s clear up one thing at the start NSAID’s actually delay healing! Specifically, they uncouple what is called oxidative phosphorylation and inhibit phospholipase C activity. Suffice to say glycosamino glycan synthesis, by the joint’s articular cartilage, is inhibited. I realize I stated earlier this web site is geared for the general public, but for those desiring a little deeper explanation of the specifics, well there it is. In the end you go to your family medical doctor, or a walk-in clinic, for the pain from whiplash and/or a back injury. Because their formal training is these types of injuries is marginal at best they will all too often prescribe an NSAID that lessons the symptom (not the actual condition itself) of pain, but delays healing of the very tissues causing the symptom you are seeking relief for.
NSAID’s far exceed any other category of medication in the treatment of neck and back pain. If you are using 2 different NSAID’s together your risk of gastrointestinal toxicity goes up by 20X!
COX-2’s are a group of NSAID’s (i.e. Vioxx, Celebrex, Mobicox, etc.) that deserve special mention. I recall when they came to market in 1999 (1998 for Vioxx), were hyped up as the newest and the greatest, only to be pulled from the market in 2004 (with the exception of Celebrex). They even had their own nick-name a.k.a. ‘Super-Aspirins’, kinder on the gut yet great at pain and inflammation relief. These were really pushed for those with osteoarthritis (degeneration) and Rheumatoid Arthritis (Inflammatory arthritis).Their predecessors (i.e. Naproxen, etc.) and even ibuprofen (Advil, Motrin, etc.) were quickly relegated to the back shelf.
I have been conducting classes, on whiplash and spinal pain in general, for a number of years. For British Columbia alone, in 2001 greater than 400,000 prescriptions (worth $2.5 million) were dispensed. I was warning about the COX-2 risks long before the ‘black box’ warnings were recommended by the U.S. FDA.
In my whiplash classes I was discussing the stats and risks associated with this group 2 years before they were pulled from the market. I would always mention the list of the more popular ones, i.e. Celebrex, Vioxx, etc., and ask how many in the class were taking them. Typically at least 50% of the hands would go up, even when it was becoming quite well known in the healthcare community of the serious ‘side effects’ (you and I call them heart attacks, strokes, blood clots and death) were becoming known.
The ball really got rolling in 2000 just after COX-2 major drug trial findings were published in the Journal of the American Medical Association and the New England Journal of Medicine. Unfortunately they pretty much only reported on the first 6 months of data. As the drug company sponsored trials continued the adverse events, that eventually got them pulled from drug store shelves, began to surface at about the 12-15 months mark.
The COX-2’s quite literally doubled one’s risk of having a heart attack as well as literally delayed would and ligament healing. Not to pick on the poor old COX-2’s too much, for ibuprofen also increases your risk of a heart attack by a factor of 1.7. Not to leave the COX-2 predecessor Naproxen (which has made a dramatic comeback) out of this for it raises the risk of heart attack by a factor of 1.4.
Naproxen is an NSAID that predated the COX-2’s. In 2007 Canadians consumed 3 million prescriptions of both the brand name and generic versions for a grand total of $70 million, according to IMS (department responsible for tracking drug sales in Canada) Health Canada.
In 2008 Health Canada proposed allowing Naproxen to be sold over-the-counter (OTC). Had they succeeded it would have made Naproxen the most powerful OTC pain killer available. It’s been available OTC, in the United States, for years. Dr. Walter Makeymowych, an Edmonton Rheumatologist, stated there was “no particular advantage” to taking Naproxen off prescription because it is several times more potent than aspirin and ibuprofen along with the risk of ulcers, cardiovascular/kidney/gastrointestinal complications.
Muscle Relaxants
Fact of the matter is you would be hard pressed to find any evidence this class of drugs has any direct interaction with muscle. They are also one of the more popular class of drugs for neck and back pain. Yes, muscles can be the actual cause of pain, but to be diagnosed with ‘muscle spasm’ as your condition, said health care provider might want to hit the books and get up to date.
If you have been given the ever popular ‘waste basket’ diagnosis of ‘soft tissue injury’ as well as the source of your pain is “you have muscles in spasm” you might want to get a second opinion. It never ceases to amaze me how often those tired old lines are used. They usually follow a ‘hunt and peck’ examination only to be accepted by the poor patient who only desires to get better and has no idea what a disservice they have just endured.
In researching this section of the web site I was hard pressed to find any evidence that any of the common antispasmotics (muscle relaxants) were any better than OTC NSAID’s at relieving pain. If that last line is true, and you look at the list of possible side effects from prescription muscle relaxants, one is left to ask why are they so popular?
Pain Killers
For the record they don’t actually kill pain. They are typically what are called opiate type drugs. They bind to the opiate receptors in your body allowing you to not feel the pain as much. Opiate containing drugs can produce numerous side effects: altered thought patterns, difficulty concentrating, dependency, mood changes, drowsiness to name but a few. Note they are what are called depressants to your central nervous system and when combined with alcohol can be fatal!
When it comes to consuming these things Canadians have been described as ‘world leaders’. We consume 2X the Europeans and 20X the Japanese. So as not to feel too guilty, the United States consumes twice what we do. With the U.S. at #1, for the largest per capita consumption of prescription narcotic drug use, Belgium comes in at #2 with Canada rounding out the top 3, for the entire world. Opioid drug use is steadily climbing and according the drug tracking arm IMS, of Health Canada, their use jumped 22% to 17 million prescriptions a year since 2002.
Canadians consume about 14,000 doses/day per 1 million population v. 4,500 for the United Kingdom v. 2,900 for Italy and 7,500 for the Australians. Dr. Jurgen Rehm (drug policy expert at the Ontario Centre for Addiction and Mental Health at the time) stated “It’s one of the few areas where we really are world class.” Unintentional fatal overdoses, of prescription opioids, doubled between 1999 and 2002. Putting that number into perspective they killed more people than either heroin or cocaine.
As mentioned earlier, the top 2 drugs responsible for fatal overdoses are Oxycodone (Oxyconton) and Fentanyl. Fentanyl (transdermal Duragesic) is many times more powerful than morphine and you get it , under prescription. It comes in a patch you apply directly to the skin.
Tylenol always comes up in these discussions so why don’t we touch on it here. Its principle ingredient is acetaminophen. It’s also found in a number of other OTC products like Midol, Pamperine, Excedrin, etc. Tylenol is the clear winner when it comes to which of its many forms are the most popular with the general public.
In researching this section of the web site I discovered a US FDA review that found >56,000 emergency room visits annually (remember just divide that number by 10 to get a close approximation as to how many Canadians are in the same boat) are due to acetaminophen overdoses. In the US about 100 people a year die from using this drug. A University of Pennsylvania pharmacist stated that number “…could be severely underestimated…” One researcher at the University of Texas Southwestern Medical Center opinioned that acetaminophen “…appears to be the leading cause of acute liver failure.”
I will close off this section of the web site with a discussion about Errors. The first national study into hospital errors in Canada was conducted in 2002 by this countries 2 largest health agencies, the Canadian Institute for Health Information and the Canadian Institute of Health Research. It’s established that about 10,000 Canadians die each year from preventable mistakes made in hospitals. In other words you have about a 3% chance of being admitted and not coming out alive. One of the studies authors was quoted as saying “…it will take many years to overturn the ‘cover-your-butt’ culture that hides tragic deaths in the health care system.” These numbers are not reproduced here to put the fear of god into anyone, about being admitted to a hospital. I only included them because it’s estimated that 80% of all medical errors are due to human error. Hopefully I have assisted in giving you something to ask informed questions about.
Hope it helps.