Teamwork makes the dream work

There are many things in life that are better as duos. Synyster Gates and Zacky Vengeance, peanut butter and chocolate, peanut butter and fried eggs, peanut butter and literally everything else, and John and Abby to name a few. You get the idea. Something about the slightly, almost sweetness of peanut butter with a savory runny fried egg is just heavenly. I could go on, and I might. Ever had peanut butter pancakes and a beer? Best breakfast ever after a 12 hour night shift. Just saying. Another combo? NSAIDs and acetaminophen for back pain. 

Back pain, specifically low back pain (LBP) is pretty common with worldwide estimates of 7-8% of people suffering from some level of LBP. Likely an understatement, especially because some people (maybe me) refuse to admit it until it becomes a really big problem. Either way, at least 577 million people as of 2017 have some LBP, likely even higher given that most of us can sit on our butts to work from home now and we all have terrible posture. Doesn't help that we have an obesity epidemic but that is for another time.

Pain management is a huge area of study and could be the subject of a new post for many years into the future. However I want to look at two quick things. First a study on the effects on non-opioid pain relievers for persistent back pain. This study found that NSAIDs or muscle relaxants alone or in combination with each other or acetaminophen were effective in reducing LBP in 1 week in a sample of over 3400 subjects. There are a few problems with the study, one being that it did not give which NSAIDs or muscle relaxants were being used or specific percentages on how many of the participants had relief. 

Either way, it is something to consider when treating patients with pain who may be hesitant to taking an opioid or who have a very high tolerance for them. A small example, 45 year old with abdominal carcinomatosis and guess what? Back pain. And pain everywhere really. The opioids could not keep up and given persistent nausea and constipation we were hesitant to give more and more. The patient was also convinced that only the opioids would work. While it is only one patient, when we explained that combinations may work better than say Tylenol alone, the patient was more willing to try the NSAID/muscle relaxant/acetaminophen combo. And, according to a verbal pain report, it worked. Not saying this should take the place of opioid pain killers but, it is a good alternative for some patients. Of course, watch for gastric bleeding and the like but still, you should be thinking about that already. 

The last I want to discuss is an article on antidepressants for pain. As someone who takes antidepressants I am interested in what they do to the body outside of the mental health effects. A meta-analysis looking at 26 comparative studies and over 25,000 adults found very little evidence to support the use of antidepressants for musculoskeletal pain. I will not go to deep in this but I find it interesting to look at alternative pain control methods and their rationales. Do these medications seem to help in that if one is depressed or suffering from a chronic pain condition that relieving some of the depression or negative feelings helps reduce the perceived pain? These are often given in lower doses than when given for depression but it may still have some effect. I don't know yet where to go with that but if I didn't have to go to work in an hour I might do more digging right now, but that will have to wait. If you know the answer or have thoughts or studies, please let me know. 




References 
Antidepressants Mostly Ineffective, 'Lackluster' for Chronic Pain by P. Anderson from Medscape Medical News from 2023, originally from the BMJ February 1st 2023.

Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017 by Wu et al. in the Annals of Translational Medicine in March 2020.

Image of generic pills from How safe are simple painkillers? on Pharmaceutical-Technology.com 

Nonopioid pharmacological management of acute low back pain: A level I of evidence systematic review by Baronici et al. in the Journal of Orthopedic Research  from February 2023.


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