The same treatments often used to relieve low back pain, which the Centers for Disease Control and Prevention says is the most common type of pain, could make it last longer, a new study finds .
Persistent use of steroids for pain relief and nonsteroidal anti-inflammatory drugs, such as ibuprofen, can actually turn a sprained back into a chronic condition, the study found.
Some medical experts cautioned against interpreting the results too broadly. The study did not use the gold standard for medical research, which would be a clinical trial in which people with back pain would be randomly assigned to take a nonsteroidal anti-inflammatory drug or a placebo and followed up to see who developed chronic pain. Instead, it involved patient observations, an animal study, and an analysis of patients in a large database.
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“It’s intriguing, but it requires more study,” said Dr. Steven J. Atlas, director of primary care practice-based research and quality improvement at Massachusetts General Hospital.
Dr. Bruce M. Vrooman, a pain specialist at Dartmouth Hitchcock Medical Center in New Hampshire, agreed, but also called the study “impressive in scope” and said that if the results hold up in a clinical trial, it could “force reconsideration”. how we treat acute pain”.
Dr. Thomas Buchheit, director of Duke’s regenerative pain therapies program, had a different opinion.
“People abuse the term ‘paradigm shift,’ but this is absolutely a paradigm shift,” Buchheit said. “There is this unspoken rule: if it hurts, take an anti-inflammatory, and if it still hurts, put a steroid on it.” But, he said, the study shows that “we have to think about healing and not suppressing inflammation.”
Guidelines from professional medical societies already say that people with back pain should start with non-drug treatments such as exercise, physical therapy, heat, or massage. These measures are just as effective as pain relievers, without the same side effects.
If the pain persists, the guidelines say, people can try nonsteroidal anti-inflammatory drugs such as ibuprofen. (Paracetamol is not an anti-inflammatory because it does not block inflammation.)
But the study, published Wednesday in the journal Science Translational Medicine, included a warning that such drug treatment advice could contribute to chronic pain that would reduce a person’s quality of life.
The study began when researchers at McGill University began looking for molecular markers in the blood that could predict which patients would have rapidly diminishing pain and which would persist.
The group took blood samples from 98 people when they first reported developing back pain and again three months after their pain began.
“What we saw was not exactly what we expected,” said Dr. Luda Diatchenko, the study’s principal investigator and a professor at McGill who specializes in the genetics of human pain.
Those who said their pain went away had rapid, intense swelling when the pain was acute. Inflammation markers then decreased over the next three months. Those whose pain persisted had no such inflammatory reaction.
“Absolutely nothing was happening” in people with chronic pain, Diatchenko said.
“It was a big difference,” he added.
Investigators continued to investigate. They studied people with a different type of pain, TMJ or temporomandibular joint disorders, which cause jaw pain. Once again, those who recovered had rapid and intense inflammatory responses.
The researchers also replicated the findings in mice, either by compressing the animals’ sciatic nerves to produce back and leg pain or by injecting the sciatic nerves with an irritant. When they blocked the animals’ immune response with dexamethasone, a steroid commonly used to treat back pain, the pain became chronic.
The group then questioned whether chronic pain was the result of pain suppression or inflammation suppression. So they gave some mice a prescription anti-inflammatory, diclofenac. Other mice received one of three other analgesics or analgesics: gabapentin, morphine and lidocaine.
Only with diclofenac did the pain persist, becoming chronic.
Those results led them to wonder: Were patients who took NSAIDs like ibuprofen or steroids like dexamethasone for back pain also more likely to develop chronic pain?
The researchers turned to data from the UK Biobank, a repository with information on the medical conditions and drug use of half a million patients. They studied 2,163 people with acute back pain, 461 of whom went on to have chronic pain. Those taking a nonsteroidal anti-inflammatory drug were nearly twice as likely to develop chronic back pain as those taking other medications or taking no medication at all, the researchers found.
Diatchenko said he doesn’t think his findings are relevant to the issue of opioid addiction. In fact, he said, “to avoid opioids, doctors started prescribing more nonsteroidal anti-inflammatory drugs.”
“We need to think more about how to treat our patients,” he said.
The tendency to use nonsteroidal anti-inflammatory drugs persists despite their mediocre performance. An analysis of randomized clinical trials found that these drugs had almost no benefit over placebo in reducing low back pain.
Atlas says short-term use of NSAIDs is probably not harmful, but adds that the new study, while not proving long-term use is harmful, “at least provides a biological mechanism that says short-term use term is not harmful”. the same as in the long term.”
Dr. James N. Weinstein, senior vice president of health at Microsoft, wants people to reconsider their instinct to pop ibuprofen pills and, as counterintuitive as it sounds, exercise instead.
Weinstein, who for 28 years was editor-in-chief of the medical journal Spine and was not involved in the new study, said he goes for a run when his back hurts. That actually makes it better.
“I love it,” he said of the study, “and I know it’s true.”
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