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May 26, 2022


WILL TAKING IBUPROFEN OR STEROIDS LEAD TO CHRONIC PAIN? HERE'S WHAT A NEW STUDY
SUGGESTS.


Daily Briefing
⋮
 * 
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A study published this month in Science Translational Medicine suggests that a
commonly prescribed pain-management treatment may actually lead to chronic back
pain, Gina Kolata reports for the New York Times.

Cheat sheets: Evidence-based medicine 101


STUDY DETAILS AND KEY FINDINGS

Professional medical societies follow a set of pain-management guidelines that
recommend people with back pain first try nondrug treatments like exercise,
physical therapy, heat or massage. "Those measures turn out to be as effective
as pain-suppressing drugs, without the same side effects," Kolata writes.

However, if the pain does not go away, the guidelines recommend nonsteroidal
anti-inflammatory drugs (NSAIDs) like ibuprofen to help manage the pain—a
recommendation that could cause chronic back pain, according to the new study.

Earlier this month, researchers at McGill University drew blood samples from 98
participants to look for molecular markers that would predict which individuals
would have persistent pain and which would have pain that quickly dissipated.

The researchers drew blood from each participant when they first reported
developing back pain and three months after their pain began.

"What we saw wasn't exactly what we expected," said Luda Diatchenko, the study's
principal investigator and a professor at McGill who specializes in human pain
genetics.

The participants who said their pain went away had rapid and severe inflammation
when their pain was acute, Kolata writes. Among those participants, inflammation
markers diminished over the next three months. Meanwhile, participants whose
pain persisted did not show the same inflammatory reaction.

"Absolutely nothing was happening" for participants with chronic pain,
Diatchenko said.

"It was a huge difference," she added.

The researchers also studied people with temporomandibular joint disorders
(TMJ), which cause jaw pain. Similarly, participants who recovered quickly had
rapid and severe inflammatory responses.

Notably, the researchers also replicated these findings in mice. To trigger back
and leg pain, they compressed the animals' sciatic nerves or injected the
sciatic nerves with an irritant. According to Kolata, when they blocked the
mice's immune response with dexamethasone—a steroid that is commonly used to
treat back pain—the pain became chronic.

The researchers questioned whether chronic pain stemmed from pain suppression or
inflammation suppression. However, they found that the pain only became chronic
with a prescription anti-inflammatory called diclofenac.

Those findings led them to question whether patients who took NSAIDs like
ibuprofen or steroids like dexamethasone to relieve their back pain were also
more likely to develop chronic pain.

To answer this question, they analyzed data from the UK Biobank. Specifically,
they studied 2,163 people with acute back pain. Of those, 461 developed chronic
pain. Ultimately, the researchers found that individuals who were taking NSAIDs
almost doubled their chance of developing chronic back pain compared with those
taking other drugs or no drugs.


COMMENTARY

Steven Atlas, director of primary care practice-based research and quality
improvement at Massachusetts General Hospital, said that short term use of
NSAIDs is not likely to be harmful. And while he said the new study does not
provide definitive proof that long term use is harmful, it "at least gives a
biological mechanism that says short term use is not the same as long term."

Still, several medical experts warned against interpreting the results too
broadly. Diatchenko said she does not believe the study's findings are relevant
to the issue of opioid addiction.

In addition, according to Kolata, "[t]he study did not use the gold standard for
medical research, which would be a clinical trial in which people with back pain
would be randomly assigned to take a nonsteroidal anti-inflammatory drug or a
placebo and followed to see who developed chronic pain. Instead, it involved
observations of patients, an animal study and an analysis of patients in a large
database."

"It's intriguing but requires further study," Atlas said.

Similarly, Bruce Vrooman, a pain specialist at Dartmouth Hitchcock Medical
Center, agreed, while calling the study "impressive in its scope" and noting
that if the results hold up in a clinical trial, it could "force reconsideration
of how we treat acute pain."

However, Thomas Buchheit, director of the regenerative pain therapies program at
Duke University, presented a different view.

"People overuse the term 'paradigm shift', but this is absolutely a paradigm
shift," Buchheit said. "There is this unspoken rule: If it hurts, take an
anti-inflammatory, and if it still hurts, put a steroid on it," he added. "But,"
he said, this study signals that "we have to think of healing and not
suppression of inflammation." (Kolata, New York Times, 5/14)

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