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New Research - NSAID's, Pain Medications and Tissue Damage

We have known for some time that there are significant mortality risks associated with "over the counter" and "prescription anti-inflammatory" medications.  These are primarily associated with gastro-intestinal bleeding, bleeding at other organs, including kidneys, liver failure, stroke, heart failure, blood clot and heart attack risks.  The risks have been so serious that numerous products have been taken off of the market and FDA warning labels have become more stringent as these risks can increase after as little as a week's use. 

Some of their common names are: Motrin, Bextra, Naproxen/Naprosyn, Celebrex, aspirin, Voltaren, Indocin, Toradol, Relafen, Daypro, Clinoril, Aleve, Lomoxicam and others. They are the most widely used drugs in the world.

The serious side-effects and deaths associated with these medications have become highlighted more and more.  However, over the past years I have come across a number of articles that have indicated that many of the conditions that NSAID's have been credited with helping, including sports injuries, have some significant risks for increasing future injuries.  Recently I have reviewed a combination of articles that clarify the broad misunderstanding about these products and the clear picture that in addition to their more serious risks, they are potentially causing many long term musculo-skeletal problems, like increased ligament, tendon and bone problems. Unfortunately, these are commonly used with younger athletes and the long term consequences of the adverse affects on these kids is yet to be realized.    

Let me clarify, the information available does not question the anti-inflammatory and pain relief these meds may provide. It is clear these products provide short term symptomatic relief. Rather, these articles look at increased mortality risk, excess bleeding and increased risk of long-term musculoskeletal problems for the benefit of some temporary relief and short term recovery. 

NSAID's are used extensively worldwide, with over 60 million Americans using them regularly.  Estimates report as many as 16,500 NSAID-related deaths annually among arthritis patients taking these drugs on a daily basis, with up to 120,000 hospital admissions each year due to gastro-intestinal complications from NSAID's.  In spite of this, NSAID's are still considered a valid option for patients with chronic pain, as medically there are limited options for treating these patients.  This includes patients with both osteo and rheumatoid arthritis, ankylosing spondylitis, gout and tension headaches. 

Fortunately as alternative practitioners, we have many comprehensive options for helping patients with chronic pain conditions.  Much of our most rewarding results come with helping patients with chronic pain.  In the future I will complete an article on how comprehensive care can make a tremendous difference for these patients. 

But let's go back to the other group of frequent musculoskeletal injuries.  This includes everything from sprains, strains, tendonitis, and fractures.  There has been extensive research into the use of NSAID's during acute injury healing.  While a majority of this research used animal models and has been mostly ignored, there are some human studies which yielded significant findings.  The problem is that the methods used on the animals can't be done on humans, and some would claim should not have been done on animals either.  However, here you can see how we learn some very important information with animal studies. 

Most of this research involves creating specific injuries to tendons, ligaments, bones and muscles, including rotator cuff injuries, knee ligament sprains, patellar tendon damage and leg fractures.  In all cases they compared groups that were given NSAID's to control groups that were given nothing.  After reviewing tissue healing microscopically and functionally, it was found that in all cases the NSAID groups had delayed healing!  The groups taking NO medications had faster and stronger tissue healing. 

What is critical to understand here is that the normal healing process goes through three necessary and specific phases.  The first of those phases is the Inflammatory Phase, followed by tissue Proliferation and then tissue Remodeling. The inflammatory phase provides specific benefits to the healing process and creates the environment necessary for the remaining phases of tissue regeneration to be successful.

The problem we have faced is that animal studies are not respected in the medical literature, which I often understand, however in this case we are talking about clear tissue differences and human studies of this kind are not available.  

The human studies for these products haver primarily focused on the short term results of decreased pain and increased mobility.  However, there is one very good example using humans where they did more than just pain and swelling analysis.  

This involved Australian army recruits who sustained ankle sprains.  Immediately after their injuries they were either given an NSAID or a placebo.  The NSAID group had less pain, more rapid recovery and more rapid normalization of exercise endurance, and less time lost from activity.  Interestingly enough, when I first read about this study that was where it left off (by the way this was funded by Pfizer, the makers of the specific NSAID used).  However, after a more thorough review it was revealed that the researchers also performed orthopedic testing designed to assess the integrity of the ligaments of the ankle.  These specific tests showed that the NSAID patients had a far greater level of ankle instability than those left untreated.  The NSAID group also had significantly less range of motion and at 6 months had greater swelling remaining. 

Based on further research, Ross Hauser, M.D. states "in the case of acute ligament injuries, NSAID's should be used for the shortest period of time possible, if used at all." He also stated that NSAID's are no longer recommended for chronic soft tissue injuries, and their use is cautioned in athletes who have ligament injuries.

Next month I will follow with an article that presents alternatives for the chronic pain patient and later for the acute injury patient also.  

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