Quality Use of Medicine
Medicine to help manage your pain
By Coralie WalesHave you ever used any of these medicines?
Aspro&brand;, Disprin&brand;, Naprogesic&brand;, Naprosyn&brand;, Brufen&brand;, Nurofen&brand;, Naprosyn&brand;, Advil&brand;.
If you have, then you have used a group of medicines called "NSAIDs" (pronounced "enseds") This article will take an in-depth view of what they are. Another name for them is "anti-inflammatories". How do they fit into the big picture?
Painkillers (Analgesics)
"Painkillers". What are they? The technical term is "Analgesic" which, according to my New Oxford Dictionary of English is a term which arose in the 18th Century having Greek origins: "an" meaning "not" and "algeein" meaning "feel pain". Painkillers can be broken down into two groups: Opioids and non-opioids. The word opioid might remind you of the word "opium" which is a substance derived from the seeds of poppies. This substance is a strong painkiller, and has been used for centuries both for medicinal and also recreational purposes. Morphine comes from opium, hence the word "opioid" or "opiate".
In the above chart, the sectors of the circle are not exact representations of each type of pain medicine usage, but they give you a guide. You can see that most commonly used pain medicine is actually paracetamol. The opiate sector includes codeine, or commonly "Panadeine&brand;". There are generic medicines with codeine in them too. These are the mildest in this category of medicine called "opiates".
You can see from the diagram that there is a large group called "NSAIDs". This is a term that stands for "Non-Steroidal Anti-Inflammatory Drug". This story is going to explain how these types of drugs work, what they are, what they are called, and who should and should not take them.
What is inflammation?
Firstly, lets look at what this word means. Again going to my New Oxford Dictionary of English the word comes from the Latin "inflammare" which means "to inflame". The important part of that word is "flame" as in fire. People experiencing inflammation often describe it as hot and burning. Inflammation is a "localized physical condition in which part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection", according to my trusty Oxford.
When you are in pain, there may be a part of that experience of pain that is due to inflammation. Inflammation is caused by chemicals released by the immune system, in response to foreign substances (like if you scratch yourself and some dirt or sand gets into the skin) or if you are exposed to bacteria or viruses. Incidentally, the immune system is the system that protects you. It releases chemicals which attack any invaders, and there are other chemicals that make the area quite sensitive so that you avoid using it. This makes sense when inflammation is short term, but there are some conditions, like arthritis, which can involve long-term inflammation due to wear and tear on the joints, and sometimes even over-activity of the immune system. In fact any condition or disease that ends with "-itis" means that inflammation is involved. For example, sinusitis is inflammation in the sinuses. "Arthritis" is inflammation of the joints ("Arth" indicates joints, from the Greek "arthron" meaning joint). Inflammation is really common, and that's where "anti-inflammatories" come in.
What are "Steroids"
Anti-inflammatory medicines may involve steroids or may not. Steroids are chemicals found naturally in our bodies. They are actually hormones. Steroids are powerful anti-inflammatory chemicals, and for pain, they are commonly provided as injections into inflamed areas, such as bursitis of the shoulder joint, or hip joint. This article is about the other type of anti-inflammatory medicine, the one that doesn't use steroids. This is why they are called "non-steroidal" anti-inflammatory medicines.
Non Steroidal Anti-Inflammatory medicine (NSAIDs)
NSAIDs are valuable painkillers with a low risk of serious adverse effects when used appropriately and by those people who have been assessed by a doctor to be suitable to take them. There are a number of NSAIDs you may have used, many of them you can buy over the counter (OTC) even in supermarkets. The way these medicines work is they block chemicals called "COX". The COX chemicals allow other chemicals to inflame an area of the body, so when they are blocked, the inflammation is reduced or even stopped, while the medicine is present. There are two types of COX chemicals, COX-1 and COX-2. COX-1 protects the stomach lining from harsh acids and other chemicals, while COX-2 is responsible for inflammation and pain.
COX-1 and COX-2 blockers
The older NSAIDs blocked both COX-1 and COX-2, which means that not only did they reduce inflammation and pain, they also blocked the protection of the stomach lining. These medicines became known to cause gastric bleeding in some cases. The list of medicines at the beginning of this article is some of those that you can get over the counter in pharmacies or sometimes in supermarkets in Australia.
By the way, you CAN continue taking Paracetamol while you are taking NSAIDs. But remember only take them as directed.
This table will give you some more examples. The left hand column gives you the technical name, the right hand gives you the trade name, or the name given to the medicine by the pharmaceutical company that makes the medicine:
| Name of Medicine | Brand or Trade Names | Common side effects | Tops for managing side effects |
|---|---|---|---|
| Diclofenac | Clonac , Diclohexal, Hexal, Dinac, Fenac, Diclac, Diclohexal, Genrx Diclofenac, Imflac, Voltaren, Voltaren Rapid | Bleeding in stomach, kidney damage, high blood pressure, heart problems | Always take medicine after eating, as this reduces the chance of having stomach problems, Contact your doctor immediately if you develop black stools or vomit that looks like coffee grounds |
| Diflunisal | Dolobid | ||
| Ibuprofen | ACT-3, Actiprofen, Advil, Brufen, Bugesic, Nurofen, Rafen, Tri-Profen | ||
| Indomethacin | Arthrexin, indocid | ||
| Ketoprofen | Orudis, Oruvail SR | ||
| Ketorolac | Toradol | ||
| Mefenamic acid | Mefic, Ponstan | ||
| Naproxen | Aleve, Anaprosx, Crysanal, Inza, Naprogesic, Naprosyn, Naprosyn SR, Nurolasts, Proxen SR | ||
| Piroxicam | Fedene/D, Genrx Piroxicam/D, Mobilis/D, Pirohexal -D | ||
| Sulindac | Aclin | ||
| Tiaprofenic acid | Surgam |
A good way to think about these medicines is that they are usually for SHORT TERM USE ONLY, not for chronic or persistent pain unless you have been given the OK by your trusted doctor. The other thing to understand about these medicines is that they should only be used strictly as directed. Double the dose DOES NOT MEAN DOUBLE THE GOOD EFFECTS!
COX-2 blockers
There has been quite a bit of media attention on this group of medicines. However, if you are not in the high-risk categories, these medicines can be really helpful. These are newer medicines that target only COX-2 chemicals involved in inflammation, thereby leaving the COX-1 chemicals, which protect the stomach lining, to do their wonderful job. This means that using a COX-2 blocker is less likely to cause stomach problems such as ulcers and bleeding. Presently in Australia, there are two available medicines in this category, Celebrex (Celecoxib) and Mobic (Meloxicam). Whilst Celebrex and Mobic are as effective as the older non-selective NSAIDs, they are considered to be safer. Having said that, there are side effects, as with all medicines you take. It is still recommended that you take these COX-2 blocking medicines after eating.
Weighing up the risks
It is important in your consideration of the risks involved with taking NSAIDs to look at the big picture. The table below comes from a recent study published in Arthritis Research & Therapy 2008. What it shows us is the relative risks of using the NSAIDs compared with other risks we are exposed in ordinary daily life. In this study, the risks of Gastro-intestinal bleeding or heart attack were looked at. There are other risks, for example renal failure, which this study did not look at. Before you decide to take any particular medicine, we recommend you discuss it with your trusted doctor.
For example, looking at the left hand column you can see here that for one of the medicines, the risk of death from either a heart attack or a gastric bleed is very low, at the 1 in 100,000 level, less likely than death by car accident. I think it is really interesting. We can often become scared or put off because of perceptions of enormous risks, when we really need to weigh up the risk, by communicating with our trusted health professionals, and informing them fully of our own health status and usage of other medicines. Something to think about!
(http://arthritis-research.com/content/10/1/R20)
Side Effects
To be an informed consumer of medicines means you know your medicine's risks and benefits. If you are pregnant, have high blood pressure, asthma, or a history of kidney or liver disease, or have had ulcers in the past, or if you are older than 65 years of age, you must be careful when taking NSAIDs. Whilst it is only a small risk, there is an increased risk of heart attack or stroke. It is important to develop a good relationship with your doctor and your pharmacist as they are important resources. When communicating with your doctor and or pharmacist, make sure you tell them about ALL your medicines, including the "natural" medicines that you might get in the supermarket or chemist, because these can have adverse effects in some combinations with NSAIDs. A good rule of thumb is that once your doctor says it is OK to take NSAIDs, don't take them for long periods. Alternate them with Paracetamol, or use lower doses of NSAID and supplement this with Paracetamol. Talk about these options with your doctor.
As a member of Chronic Pain Switzerland we encourage you to be as informed as you can about the medicines you take. Did you know that you can ring "Medicines Line" and talk to a pharmacist between 9am and 6pm Monday to Friday, Eastern Standard Time (EST) for the cost of a local call (mobile calls may cost more). This is a service set up by the Government to help people understand the medicines they are using, and to use them in the most effective and safe way possible.
