Map of life expectancy at birth from Global Education Project.

Tuesday, July 14, 2015

No good options for chronic pain

In some not so good news, the FDA has substantially strengthened its warning on the risk of non-steroidal anti-inflammatory drugs, NSAIDS. Although aspirin is literally a non-steroidal anti-inflammatory, and has overlapping mechanisms of action with these drugs, it is not formally classified as an NSAID, basically because the term is designed to exclude it, as I will explain.

NSAIDS include ibuprofen, naproxen, and celecoxib, which was at one time heavily advertised based on safety claims. These are widely used by people with osteoarthritis and other chronic pain conditions. The problem, as the FDA now concludes, is that they strongly raise the risk of heart attacks and ischemic strokes. The risks are mostly reported in relative terms, so it's hard to pin down the absolute risk for an individual. But the risk is substantial even for people without heart disease or risk factors. And obviously, you really don't want a stroke or a myocardial infarct. The risk increases with dose and duration of use, which means that the kinds of regimens people take for moderate to severe arthritis are the most dangerous.

Aspirin actually lowers the risk of heart attacks and ischemic strokes, which is terrific, but it creates a risk of bleeding, including (comparatively rarely) hemorrhagic strokes and more commonly gastrointestinal bleeds. You might say, well, that's better than a heart attack, and I tend to agree with you, but doctors are very concerned about these events because it can be hard to find the bleeding point and they can be fatal  -- although they can also be fixed and Bob's your uncle. Anyway, for that reason, doctors don't generally recommend high dose aspirin long term. (Low dose aspirin is beneficial for people with cardiac risk, but at a dose that's too low for pain management.)

Then there is acetaminophen (Tylenol). It reduces pain but not inflammation, so it's not the most useful for arthritis anyway. But the big problem is that the difference between a clinically effective dose and liver damage is very narrow, especially but not exclusively for people who drink alcohol. Liver damage from acetaminophen is distressingly common.

Then there are opioids, and we already know what's going on with that. They are definitely not recommended for arthritis pain or most chronic pain syndromes.

And that leaves basically nothing as far as pharmaceutical treatment. Of course people can choose to accept risks in exchange for reduced pain and disability, and I'm sure many will. But we need better options. As the population ages, arthritis becomes more and more prevalent. I was lucky enough to have a form of arthritis in my hand that was treatable by surgery, but without that option, I would be very unhappy today. I was in constant pain and I faced real limitations on activities I cared about. But I never did take pills for it, for all the above reasons.

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