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Herniated disk; Sciatica
Patients should understand that most people who have sudden low back pain, even with sciatica, have a high likelihood of substantial improvement over the first month.
The most commonly prescribed medications for the treatment of back pain are nonsteroidal anti-inflammatory drugs (NSAIDs). Evidence suggests that short-term use of NSAIDs brings effective relief in patients with acute back pain. The benefits of NSAIDs for chronic back pain are less certain.
There are dozens of available NSAIDs:
In April 2005, the Food and Drug Administration (FDA) asked drug manufacturers of prescription NSAIDs to include with their products the same warning label used for the COX-2 inhibitor celecoxib (Celebrex). This "black box" warning, the FDA's strongest, emphasizes the increased risks for cardiovascular events (heart-related problems) and gastrointestinal (digestive tract) bleeding associated with the use of these drugs. The FDA also requested manufacturers of OTC NSAIDs to be more specific in their labels concerning potential cardiovascular and gastrointestinal risks. Due to its proven heart benefits, aspirin was excluded from these labeling revisions. In December 2006, the FDA proposed even stronger labeling changes to highlight the potential of these drugs to cause liver damage, as well as risks of alcohol and drug interactions with NSAIDs.
Long-term, regular use of NSAIDs can increase the risk for heart attack, especially for people who have a heart condition. Long-term use of NSAIDs is also the second most common cause of ulcers and gastrointestinal bleeding. To reduce the risks associated with NSAIDs, take the lowest dose possible for pain relief.
Other possible side effects of NSAIDs may include:
Long-term use of NSAIDs is the second most common cause of ulcers. Ulcers caused by NSAIDs are more likely to bleed than those caused by the bacteria Helicobacter pylori.
Those at high risk for bleeding include people over age 60, anyone with a history of ulcers or gastrointestinal bleeding, patients with serious heart conditions, people who abuse alcohol, and those who take medications such as anticoagulants (blood thinners) and corticosteroids.
Proton-pump inhibitor (PPI) drugs may help prevent and heal ulcers caused by NSAIDs. PPIs include omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid).
COX-2 Inhibitors (Coxibs). Coxibs inhibit an inflammation-promoting enzyme called COX-2. This drug class was initially thought to provide benefits equal to NSAIDs but cause less gastrointestinal distress. However, following numerous reports of heart problems, skin rashes, and other adverse effects, the FDA re-evaluated the risks and benefits of this drug class. This lead to the removal of rofecoxib (Vioxx) and valdecoxib (Bextra) from the United States market. Celecoxib (Celebrex) is still available, but patients should ask their doctor whether the drug is appropriate and safe for them. In December 2006, the FDA approved celecoxib for the relief of symptoms of juvenile rheumatoid arthritis in patients ages 2 years and older.
Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. While the drug has opioid-like properties, it is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea, but does not cause the severe gastrointestinal problems that NSAIDs can. Some patients who take tramadol experience severe itching. A combination of tramadol and acetaminophen (Ultracet) is now available. It provides more rapid pain relief than tramadol alone.
Narcotics are pain-relievers that act on the central nervous system. They are the most powerful medications available for the management of pain.
There are two types of narcotics:
Opioids are effective for short-term relief of back pain. Using them for longer than 16 weeks to treat low back pain has not been well studied and may increase the risk of abuse, if a health care provider does not manage usage well.
Newer ways to deliver pain medicine have been developed. A skin patch containing an opioid called transdermal fentanyl (Duragesic) may relieve chronic back pain more effectively than oral opioids.
Common side effects of opioids include anxiety, constipation, nausea, vomiting, dizziness, drowsiness, paranoia, urinary retention, restlessness, and labored or slow breathing. Addiction is a risk, although less than is commonly believed when these medications are used for pain relief. In fact, when prescribed properly, use of opioids for chronic pain can be safer in some cases than on-going use of NSAIDs. Unfortunately, opioid abuse among young people is a major concern. Unless the pain is very severe, experts advise against routinely prescribing opioids.
Injections of corticosteroids (commonly called steroids) are sometimes used to treat low back pain caused by nerve impingement. The injection is placed into the epidural space, just inside the outer membrane covering the spine.
The injection is directed as close to the location of the affected nerve as possible. Corticosteroids reduce inflammation.
Studies that measure the benefits of steroid injections on sciatica or low back pain are conflicting.
No high quality studies have shown that these injections provide long-term benefit for most patients, compared to more conservative treatments. However, reasonable evidence shows that patients receive short-term pain relief, generally over a 1 - 2 month period, from these injections.
Serious and painful side effects, including meningitis and inflammation, are possible. However, such risks are very low.
Epidural steroid injections for spinal stenosis may provide short-term relief of pain but generally do not improve the patient's daily functioning, nor do they help patients avoid surgery.
Researchers are investigating whether injections of botulinum toxin (Botox) in the lower back can safely and effectively relieve pain. Botox is commonly used to smooth out wrinkles and to treat other neuromuscular disorders. Very small amounts of Botox temporarily paralyze muscle tissue. Some studies have suggested that Botox may be of help in relieving chronic low back pain but its role in the treatment of back pain has not yet been determined.
Some studies show that antidepressants may lessen the severity of pain in some patients, although they have little effect on daily functioning. Antidepressants called tricyclics may be effective painkillers in non-depressed people with chronic back pain. Such antidepressants include amitriptyline (Elavil, Endep), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), nortriptyline (Pamelor, Aventyl), and maprotiline (Ludiomil).
Tricyclics can have severe side effects. Nonetheless, experts believe there is a useful role for these drugs that warrants further investigation.
A recent review of existing studies found no clear evidence that antidepressants help people with chronic low back pain. However, the reviewers noted that antidepressants help in other cases of chronic pain and that additional, larger studies are needed to clarify their effect on chronic low back pain.
A combination of nonsteroidal anti-inflammatory drugs and muscle relaxants -- such as cyclobenzaprine (Flexeril), diazepam (Valium), carisoprodol (Soma), or methocarbamol (Robaxin) -- are sometimes used for patients with acute low back pain. Evidence has shown that they can help relieve non-specific low back pain, but some experts warn that these drugs should be used cautiously, since they target the brain, not the muscles. Patients who take muscle relaxants may experience a number of central nervous system side effects, such as drowsiness. The muscle relaxant Soma can be addictive and does little more than induce sleep.
Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.
Most herbal remedies used for back pain are said to have both pain-relieving and anti-inflammatory effects. A few have been found to have some benefit when compared to placebo or sugar pill. However, none of these have been compared to other standard treatments.
White willow bark, bromelain, and Boswellia have blood-thinning properties and can interfere with anticoagulant medications, such as warfarin (Coumadin).
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